2013_0513 (3)CIIECK ONE:
IRRIGATION
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DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Prin'l ❑ Pressure Vacuum Breaker
Double Check Valve [7 Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
i / j--) C
Located At
The above is certified to be true.
Firm Name
Certified Tester
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Ti ❑
Leaked ❑
nSid
nSid
RP} sid
❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DG- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name
Certified Tester
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy