2014_0226_RPZ (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
' , A 1 A
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 par=eters.
Reduced Pressure Principle
Double Check Valve
Manufacturer ,4 /4i ,lz+
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
M Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name.
Firm Address C .)
Gauge #:', -il s
Date last accuracy tested J;R
Certified Tester3's`
Cert. Testa No. / Ph7 k. s 7 -1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight
Leaked C
Opened at
psid
Opened at
nsid
nsid
a•a�'ty
RP- ^l_. psid
Leaked C
7.0
Did not Open C
Leaked C
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed not o
Opened at
nsid
Opened at
nsid
_ nsid
RP sid
The above is certified to be true.
Firm Name.
Firm Address C .)
Gauge #:', -il s
Date last accuracy tested J;R
Certified Tester3's`
Cert. Testa No. / Ph7 k. s 7 -1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy