2014_0129 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number' s
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
r
Located At
The above is certified to be true.
Firm Name PJ" _Y:'Certified Testa
Firm Addtess U6`X`f Lp3 [4.L4 t t -I DQ Cent T o. " ����� �' , Date
Gauge # (a RY`J'..!j c1
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
; J
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
Tight
sid
Leaked
nsid
nsid
.
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
______--p sid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name PJ" _Y:'Certified Testa
Firm Addtess U6`X`f Lp3 [4.L4 t t -I DQ Cent T o. " ����� �' , Date
Gauge # (a RY`J'..!j c1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy