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CHECK ONE:
IRRIGATION FIRELINE
BACEILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # —7
LOCATION OF SERVICE: / !
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
^_ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number bJ�y
Serial Number I/ )-/ ' _-
Size
Located At 4L2
The above is certified to be true.
!��! ' Tester
Firm Name __� � �� Certified Te
Firm Address _�� Y t / f % Cert. Testy No. - /iz" t Date
Gauge # 971yy L� >
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
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
Dsid
Tight ❑
RP- LL Dsid
Lza;e ❑
Leaked ❑
nSid
DSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
Dsid
DSid
RP sid
The above is certified to be true.
!��! ' Tester
Firm Name __� � �� Certified Te
Firm Address _�� Y t / f % Cert. Testy No. - /iz" t Date
Gauge # 971yy L� >
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy