2014_0602 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Size
Model Number ; Located At
Serial Number
The above is certified to be true.
Firm Name
Certified Tester
f"//
Firm Address K +.fir ` , Cent Tester No. Date 11
Gauge # 7 / 4
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
Tight o
Closed Tight ❑
Leaked ❑
Opened at
sid
Opened at
osid
osid
RP - _psid
Leaked o
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true.
Firm Name
Certified Tester
f"//
Firm Address K +.fir ` , Cent Tester No. Date 11
Gauge # 7 / 4
Date last accuracy tested ?�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy