2014_0327 (4)CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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
Model Number
Serial Number
a-,g i / 5 Size
Located At
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Testa No. Date
Gauge #
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
oSid
Tight ❑
Leaked ❑
psid
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 ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Testa No. Date
Gauge #
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy