2014_0224CHECK ONE:
IRRIGATION_ V11 DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: "f
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 Reduced Pressure Principle
C Double Check Valve
Manufacturer
Model Number
Serial Number��U��`
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
/!
Size
Located At
The above is certified to be true.
Firm Name ,, Certified Testa /,—
Firm Address fu L.• l �� _ ` < � Cert. Testa No. / /44%• YI PI Date Z� -
Gauge # ",)V i G u
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
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight C
RP- %' ` Sid
Leaked p
Closed Tighf `
Leaked D
Opened at
osid
Opened at
Sid
Did not Open o
osid
Leaked C
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
Sid
Opened at
Sid
oSid
RP Sid
The above is certified to be true.
Firm Name ,, Certified Testa /,—
Firm Address fu L.• l �� _ ` < � Cert. Testa No. / /44%• YI PI Date Z� -
Gauge # ",)V i G u
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy