2014_0602CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # f 7 ?
LOCATION OF SERVICE:
l�
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 h "// f
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name L-Pd (ti,4 r
Firm AddressISS��
7 .) V
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
Sid
oSid
RP -_ psid
Leaked p
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
oSid
Opened at
oSid
oSid
RP Sid
The above is certified to be true.
Firm Name L-Pd (ti,4 r
Firm AddressISS��
7 .) V
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy