2014_0103 (3)CIIECK 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 par=eters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number / E=
The above is certified to be true.
Firm Name ¢ Certified Tester
Firm Address ;' ` 24 ? `7 e-:, 11 -7 Cent. Tester No. -A±z7 ""a ='"" qM Date
Gauge #
Date last accuracy tested ,fib , %-7,��
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 ❑
osid
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 ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name ¢ Certified Tester
Firm Address ;' ` 24 ? `7 e-:, 11 -7 Cent. Tester No. -A±z7 ""a ='"" qM Date
Gauge #
Date last accuracy tested ,fib , %-7,��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy