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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 backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
❑
Manufacturer
Reduced Pressure Principle
Double Check Valve
o 1�s
Model Number CA.> 7M 1
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size -2-
Located At A-, • � h �( ��+ � (1r
The above is certified to be true.
Firm Name
Firm Address ? k 132 2
Gauge #
Date last accuracy tested f
Certified Tester
Cert. Tester No. 1 f' ` ' < C_.: 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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
Dsid
oSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
osid
oSid
RP Sid
The above is certified to be true.
Firm Name
Firm Address ? k 132 2
Gauge #
Date last accuracy tested f
Certified Tester
Cert. Tester No. 1 f' ` ' < C_.: Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy