2013_0607CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE'
. I
I BACXFLOW PREVENTION ASSEMBLY TEST AND MAINI'ENANC. E, REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE:
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e / Reduced Pressure Principle a Pressure Vacmmi Breaker
❑/ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number �9 C1 CS % .
The above is certified to be true.
Firm Name C Ll Cerdfwd T
Firm Address Cork Tester N Date
Gauge # �e I C13
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
1st Check
2nd Check
Relief Valve.
Air Inlet
Check Valve
Initial Test
DC- Closed J,�
Tight X
RP ----_Dsid
In - ❑
Closed Tight X
Leakeda ❑
Opened at
d
Opened at
d
Did not Open o
_--I)sid
Leaked o
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
�nsid
� d
RP
The above is certified to be true.
Firm Name C Ll Cerdfwd T
Firm Address Cork Tester N Date
Gauge # �e I C13
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy