2014_0528CHECK ONE:
IRRIGATION
DOMESTIC
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FIRELIN E
BACI{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: '�
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r
The baclflow 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
C Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
,� /
Certified Taster
Cent. Taster No. Dated =fir'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy D
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 C
Leaked ❑
Opened at
p si
Opened at
nsid
nsid
RP-_psid
Leaked p
Did not Open o
Leaked ❑
Repairs
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Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
nsid
Opened at
vsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested
,� /
Certified Taster
Cent. Taster No. Dated =fir'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy D