2013_0926CIIECK ONE:
IRRIGATION
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number `J L Located At
Serial Number /j lk5 71
rr�
The above is certified to be true.
Firm Name le
Firm Address 1
Gauge # , �U
Date last accuracy tested
Certified Tester
Cert. Tester No. i!' r t,/ �Io. (� 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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight Cl
psid
osid
RP sid
The above is certified to be true.
Firm Name le
Firm Address 1
Gauge # , �U
Date last accuracy tested
Certified Tester
Cert. Tester No. i!' r t,/ �Io. (� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy