2014_0103 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK FLOW 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 parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle o Pressure Vacuum Breaker
n Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer ! r : Size
Model Number Located At c c p
Serial Number
The above is certified to be true.
Firm Name r->. . , < <: -P v ' � l e ' Certified Tester 9 m.. l ; H '
Firm Address 11 1 / '' , % 7 4> Cert. Tester No. a > 4,. Date
Gauge #
Date last accuracy tested , (r ,,
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 o
osid
nsid
RP- _psid
Leaked ❑
2 '
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name r->. . , < <: -P v ' � l e ' Certified Tester 9 m.. l ; H '
Firm Address 11 1 / '' , % 7 4> Cert. Tester No. a > 4,. Date
Gauge #
Date last accuracy tested , (r ,,
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy