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CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANC7E REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below hit been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufactureri�`
Model Number
Serial Number�e_
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name l Y Gr�Jr.'�� Certified Tester~
Firm Address .� ,/ /� ►-- 1.�.H�t Cert. Testa No. Date
Gauge #
t,
Date last accuracy tested I,- j... /3_
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
nsid
Tight ❑
RP- 2L L Dsid
Leaked ❑
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__ nsid
Repair
Tight ❑
Dsid
Dsid
RP psid
The above is certified to be true.
Firm Name l Y Gr�Jr.'�� Certified Tester~
Firm Address .� ,/ /� ►-- 1.�.H�t Cert. Testa No. Date
Gauge #
t,
Date last accuracy tested I,- j... /3_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy