2014_0423 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
Ln.
The bacifflow 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
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer k) f i C Size
Model Number 71"S 7 t, Located At
Scrial Number N H 3d9 -
The above is certified to be true.
Firm Name
Certified Tester
Firm Address Cert. Testa No. Date
Gauge #
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
psid
Opened at
oSid
nSid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
C1erined
and
Materials
Used
1:J P-
Test After
R4Pair
-'
DC- Closed
Tight ❑
RP sid
Closed Tight ❑
Opened at
nsid
Opened at
vSid
nSid
The above is certified to be true.
Firm Name
Certified Tester
Firm Address Cert. Testa No. Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy