2014_0530CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number
Serial Number`- �'�--�
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
eat
Size
c.f
Located At
The above is certified to be true.
Firm Name ' krf,,A 1 /r. T/� Certified Testa IZ',-.
Firm Address �v `f Cat Testa No. `f Date
Gauge # 12 ; &LL, It
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 b-
Opened at
Opened at
uSid
Tight ❑
RP -_-1 Dsid
Leaked ❑
usid
uSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
Dsid
DSid
RP Sid
The above is certified to be true.
Firm Name ' krf,,A 1 /r. T/� Certified Testa IZ',-.
Firm Address �v `f Cat Testa No. `f Date
Gauge # 12 ; &LL, It
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy