2014_0408CHECK 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 parameters.
C
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At 1�er
The above is certified to be true.
Firm Name ' - 7 Certified Tester
Firm Address. J2 y � / --- ►-%- �:.—�— % Cert. Tester No. Date
G
Gauge # POMW111-1
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
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 ' - 7 Certified Tester
Firm Address. J2 y � / --- ►-%- �:.—�— % Cert. Tester No. Date
G
Gauge # POMW111-1
Date last accuracy tested ,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy