2012_0423CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bac0ow prevention v
assemb ldetailed below has been tested and maintained as required by TNRCC
resuladons and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
(^ Double Check Valve
Manufacturer
Model Number
Serial Number 1)
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
57
Size
Located At Q ` �C to
The above is certified w be true.
Firm Name j i i�lTs� Certified Tester DU
Firm A Cat. Testa No. 4r- M, 11� Date q4
i ho n -7
Gauge #
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
Closed Tight ❑
Opened at
Opened at
oSid
Tight t 11
`
Leaked ❑
Dsid
oSid
RP- Psid 1
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified w be true.
Firm Name j i i�lTs� Certified Tester DU
Firm A Cat. Testa No. 4r- M, 11� Date q4
i ho n -7
Gauge #
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy