2014_0602 (2)BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 1 `)
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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ? ✓' �� ^ ` Size
Model Number 7
Serial Number
Located At I la
The above is certified to be true.
Firm Name Certified Tester
Firm Address � �1, �,�' "� �l Cat Testa No. 1�� 1 / 71 Date
Gauge # ! SG % 11119G,
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
osid
Tight ❑
Leaked ❑
sid
osid
RP- __psid
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
1
11
The above is certified to be true.
Firm Name Certified Tester
Firm Address � �1, �,�' "� �l Cat Testa No. 1�� 1 / 71 Date
Gauge # ! SG % 11119G,
Date last accuracy tested
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy