2014_0522CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
J/
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number
Sehal Number 0// 5
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Y U �h� Certified Tester
Firm Address ?� ? .► �r P(221)/ 7 ' N
Celt Tester No. Date
Gauge # Ci-
Date last accuracy tested 7 n
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 ❑
Leaked C3
Opened at
Dsid
Opened at
osid
osid
It -_„ psid
Leaked ❑
Did not Open ❑
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
Y U �h� Certified Tester
Firm Address ?� ? .► �r P(221)/ 7 ' N
Celt Tester No. Date
Gauge # Ci-
Date last accuracy tested 7 n
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy