2013_1226 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKF'LOW 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 C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge # _
Date last accuracy tested JE ,-Z zi „ -1 3
Certified Tester
Cert. Tester 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 Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
vSid
Opened at
nSid
nSid
RP- pSid
Lza;ed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
Sid
Opened at
nSid
nSid
IL-
RP Sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # _
Date last accuracy tested JE ,-Z zi „ -1 3
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy