2014_0129CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: 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 cciffied to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
0 Atmosphere Vacuum Breaker
Size I
Located At
The above is certified to be true.
FixmName
tertified Testef
Firm Address Cert. Testa No. Date
Gauge #
Date last accuracy tested )--7 —1 �
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
Tight
Leaked ❑
Closed Tight
Leaked
Opened at
sid
Opened at
Si d
Did not Open 0
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight ❑
Opened at
Opened at
—______psid
Repair
Tight ❑
osid
nsid
RP—_---psid
11
The above is certified to be true.
FixmName
tertified Testef
Firm Address Cert. Testa No. Date
Gauge #
Date last accuracy tested )--7 —1 �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy