Subaru- CS160210 CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.
LOCATION OF SERVICE:
The backflow 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number
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 0 Opened at Opened at osid
Tight ❑ Leaked 0 psid _psid
RP-__psid
Leaked 0 Did not Open 0 Leaked ❑
Repairs
and
Materials
Used
Test After DC-Closed Closed Tight 0 Opened at Opened at nsid
Repair Tight 0 psid _psid
RP psid
The above is certified to be true.
Firm Name Certified Tester
Firm Address Cert. Tester No. Date
Gauge #
Lit
Date last accuracy tested
White - Customercopy Yellow - City Copy Pink - Tester's Copy