2013_1023 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
^_ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Tester
Cent. Tester No. Date
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
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__ nsid
Repair
Tight ❑
osid
osid
RP Sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
Certified Tester
Cent. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy