2014_0209CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CTY OF COPPELL
LOCATION OF SERVICE: 12
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ,�� Size
Model Number I Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address �,
Gauge # <, z
Date last accuracy tested
Certified Test n
er
Cat. Testa No. `i %!� { /u� ! Date
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
nsid
Tight ❑
Leaked ❑
' h, pSid
nSid
lz -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address �,
Gauge # <, z
Date last accuracy tested
Certified Test n
er
Cat. Testa No. `i %!� { /u� ! Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy