2014_0508 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bac0ow 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 Breaker
^_ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer 44 r,
Model Number 6) U `7
Serial Number
Size
Located At O u i 5/")e
The above is certified to be true.
Firm Name 41 L Certified Testa
Firm Address
z? �j ; ; ;�,- rya. #�, Cat. Testa No. , ;,,c4 Date 4 - _!g
,4t
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
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Tight ❑
Leaked ❑
nsid
usid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
nsid
usid
RP sid
The above is certified to be true.
Firm Name 41 L Certified Testa
Firm Address
z? �j ; ; ;�,- rya. #�, Cat. Testa No. , ;,,c4 Date 4 - _!g
,4t
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy