2014_0224CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIv E 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 ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number �1
Serial Number
Size
Located At
The above is certified to be true.
i
Firm Name / 1 Certified Tester
Firm Address `� (� / /�— %r�� �, Cert. Tester No Date 2`
Gauge # li1/ //, L-
Date last accuracy tested
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
Dsid
Opened at
usid
usid
RP- Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
Dsid
Opened at
DSid
usid
RP sid
The above is certified to be true.
i
Firm Name / 1 Certified Tester
Firm Address `� (� / /�— %r�� �, Cert. Tester No Date 2`
Gauge # li1/ //, L-
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy