2013_0121CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
r.
?,5 /g
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.
C Reduced Pressure Principle
n Double Check Valve
Manufacturer /' o
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name ' /= ✓ Certified Tester
Firm Address V' 9,°7c7 Cert. Tester No, t' ?`?`? `' Date
Gauge #
Date last accuracy tested �—/ b. //, �
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 ❑
Closed Tight o
Leaked ❑
Opened at
nsid
Opened at
nsid
nsid
RP- psid
Leaked ❑
Did not Open ❑
Leaked O
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight O
Opened
sid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ' /= ✓ Certified Tester
Firm Address V' 9,°7c7 Cert. Tester No, t' ?`?`? `' Date
Gauge #
Date last accuracy tested �—/ b. //, �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy