2013_1226 (4)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
e Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer"
::
Size
._
Model Number
Located At
Val'
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge # 0 (f l u ci s,
Date last accuracy tested
Certified Tester
Cent. 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 Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
osid
osid
RP- __,psid
I,zalced ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # 0 (f l u ci s,
Date last accuracy tested
Certified Tester
Cent. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy