2013_724CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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 O Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
--I G0% -'
Size
Located At
The above is certified to be true.
Firm Name 'Wry , Certified Testes Cc V
Firm Address � ; �- Cert Tester No. q.� Date
Gauge # \0 W191 b -�
Date Last accuracy tested \ C! ' N _ 0\-1
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
usid
Tight ❑
Leaked ❑
psid
uSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
uSid
uSid
RP sid
The above is certified to be true.
Firm Name 'Wry , Certified Testes Cc V
Firm Address � ; �- Cert Tester No. q.� Date
Gauge # \0 W191 b -�
Date Last accuracy tested \ C! ' N _ 0\-1
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy