2013_1226 (2)�►.^:>s� Ra+... *;,. T •= v.' *.- '°- A_!R'�'_,�gwy`g+�Pt.'. :� .rte
CHECK 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
M Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number Located At
Serial Number
''' 1%
The above is certified to be true.
Firm Name
Firm Address
Gauge # y : it Lr'i S
Date last accuracy tested
Certified Tester
Cat. Testa No. 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 Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
oSid
oSid
PIP-- Sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
vSid
Opened at
oSid
______p sid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # y : it Lr'i S
Date last accuracy tested
Certified Tester
Cat. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy