2014_0602 (5)CHECK ONE:
IRRIGATION
DOMESTIC
P7
FIRELINE —911-,
BACKFLOW 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 C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name Certified Testa
Firm Address � ' ` �'� Cert. Testa No. 711,r Date �- y
Gauge #
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
f Air Inlet
Check Valve
Initial Test
DC- Closed
Tight (� k ❑
Closed Tight ❑
Leaked ❑
Opened at
% 3' nsid
Opened at
nSid
nsid
RP- psid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nSid
nSid
RP sid
The above is certified to be true.
Firm Name Certified Testa
Firm Address � ' ` �'� Cert. Testa No. 711,r Date �- y
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy