2014_0327CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
The bacltilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be opera ting within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name I" Certified Tester
Firm Address ! �'' 7 L61,yX, -1 Ty Cat. Tester No. dPr 00 U 76?,2 Date
Gauge # " �// 7 f''f
Date last accuracy tested
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
vsid
Tight ❑
Leaked ❑
vSid
vSid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
vSid
vSid
RP sid —
J
The above is certified to be true.
Firm Name I" Certified Tester
Firm Address ! �'' 7 L61,yX, -1 Ty Cat. Tester No. dPr 00 U 76?,2 Date
Gauge # " �// 7 f''f
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy