2014_0226CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKMOW 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
The above is certified to be true.
P
Firm Name Certified Tester
Firm Address 'C a
Cert. Testa No i+� Date,
Gauge # Sf r
Date Last accuracy tested ' �' !� I ?
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
usid
Tight ❑
Leaked O
psid
usid
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
nsid
usid
RP sid
The above is certified to be true.
P
Firm Name Certified Tester
Firm Address 'C a
Cert. Testa No i+� Date,
Gauge # Sf r
Date Last accuracy tested ' �' !� I ?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy