2013_0204CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ` /
The bacifflow 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breakers
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer A—AA Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name Ar- .I , _7- � Certified Tester
Firm Address r ° "' t/ -' '�' ' - .. / Cat. Testa No. �' ' "f Date
Gauge #
Date last accuracy tested '�- 31 - ✓ y
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 ❑
RP -osid
Leaked ❑
Closed Tight LZ
Leaked ❑
Opened at
3. c' psid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
,.
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
oSid
Opened at
oSid
osid
RP sid
The above is certified to be true.
Firm Name Ar- .I , _7- � Certified Tester
Firm Address r ° "' t/ -' '�' ' - .. / Cat. Testa No. �' ' "f Date
Gauge #
Date last accuracy tested '�- 31 - ✓ y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy