2014_0530CIIECK ONE:
IRRIGATION= __'
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: a
Y
The bad.-Dow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number
Serial Number 114
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name _ Certified Tester
Firm Address `� w, / `:4_y Ccrt. Tester No. Date _��f
Gauge # D7�,.i //L/
Date last accuracy tested 61-k17
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 ❑
psid
oSid
RP - Sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
osid
oSid
RP Sid
The above is certified to be true.
Firm Name _ Certified Tester
Firm Address `� w, / `:4_y Ccrt. Tester No. Date _��f
Gauge # D7�,.i //L/
Date last accuracy tested 61-k17
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy