2014_0228CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac0ow 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 Principle C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturers ' Size
Model Number Located At
1z
Serial Number ^ J
The above is certified to be true.
Firm Name
Firm Address - "Y - " ' ` R A n 7 -Ivr = 411 -).y
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa No.'s` 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
osid
Opened at
osid
osid
RP - _psid
Leaked ❑
Did not Open ❑
Leaked O
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address - "Y - " ' ` R A n 7 -Ivr = 411 -).y
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa No.'s` Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy