2014_0123CHECK 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number 77
Serial Number l / 1.7�
Size
Located At
The above is certified to be true.
� r
Firm Name rii, Certified Tester
Firm Address 1. t, Cat. Tester No./Y14-0,4" �- tl Date
Gauge # (2 &,L4f „(t[_
Date last accuracy tested l G'
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` 1
Opened at
Opened at
flSid
Tight ❑
RP - -77 osid
Leaked ❑
DSid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
� r
Firm Name rii, Certified Tester
Firm Address 1. t, Cat. Tester No./Y14-0,4" �- tl Date
Gauge # (2 &,L4f „(t[_
Date last accuracy tested l G'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy