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CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
0/2ty,
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 C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number ' �! /� G ) A Located At
Serial Number / //o 5712
The above is certified to be true.
Firm Name rcn Certified Tester
Firm Address �, !„ H- 30 <: Cert. Tester No.
Gauge # I'lo. -k ` '�
Date last accuracy tested
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
osid
Tight ❑
Leaked ❑
nSid
oSid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nSid
oSid
RP sid
The above is certified to be true.
Firm Name rcn Certified Tester
Firm Address �, !„ H- 30 <: Cert. Tester No.
Gauge # I'lo. -k ` '�
Date last accuracy tested
Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy