2014_0226 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer ,` )r..
Model Number -14 X -----
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
�r
Size
Located At
The above is certified to be true.
Firm Name t •g�Lkg Certified Tester 3�r.IA
u
Firm Address �G x TZ!34 1,1 �x Cat. Taster No. ��:�,Z Date % -�4
Gauge # _`)73i'7�
Date last accuracy tested ,,;Z - j j
f
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 -nsid
Leaked ❑
nsid
nsid
a •a.�. I�
Leaked ❑
:�
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
�osid
RP Sid
The above is certified to be true.
Firm Name t •g�Lkg Certified Tester 3�r.IA
u
Firm Address �G x TZ!34 1,1 �x Cat. Taster No. ��:�,Z Date % -�4
Gauge # _`)73i'7�
Date last accuracy tested ,,;Z - j j
f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy