2013_1226 (5)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 baclflow 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
0 Reduced Pressure Principle C Pressure Vacuum Breaker
C 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 # ('l i I l 0,S t
Date last accuracy tested C 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 0
Closed Tight 0
Leaked 0
Opened at
nSid
Opened at
oSid
nSid
RP- pSid
Leaked 0
Did not Open 0
Leaked 0
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight o
Opened at
nsid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # ('l i I l 0,S t
Date last accuracy tested C 3
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy