2014_0217CIIECK 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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number !"1 /_7 lT -ae _
The above is certified to be true.
Firm Name i Certified Tester
Firm Address 4/ Y / Cert. Testa No. Date
Gauge # %s? /c,",-� / „' ° A.
Date last accuracy tested 12
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
nsid
Tight
RP- t Dsid
Leaked ❑
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test A8a
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
Dsid
RP sid
The above is certified to be true.
Firm Name i Certified Tester
Firm Address 4/ Y / Cert. Testa No. Date
Gauge # %s? /c,",-� / „' ° A.
Date last accuracy tested 12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy