2014_0219CHECK ONE:
IRRIGATION / _ DOMESTIC
FIRELINE
BACHnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # t�-
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer ! �v
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Model Number I- lam , Located At
Serial Number /�`/j -� 1-fa ` }
The above is certified to be true.
Firm Name , iI f Certified Testes /Z"
v
Firm Address Ccrt. Tester No. ' f Y Date
AN BREAKER
Check Valve
vsid
Leaked ❑
osid
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
i r _
Closed Tight `
Opened at
Opened at
Tight ❑
Leaked ❑
vsid
vSid
paid
Leaked ❑
Did not Open ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
Repair
Tight ❑
vSid
vSid
RP Sid
The above is certified to be true.
Firm Name , iI f Certified Testes /Z"
v
Firm Address Ccrt. Tester No. ' f Y Date
AN BREAKER
Check Valve
vsid
Leaked ❑
osid
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy