2013_0606 (4)! CHECK ONE:
IRRIGATION DOMESTIC FIRELINE _F
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: US Postal Service, 951 W. Bethel Road
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 C Pressure Vacuum Breaker
❑Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Ames Size 4 - - - --
Model Number 2000
Serial Number
1012E02
Located At Riser # 3
The above is certified to be true.
Professional Backflow
Firm Name - _ -- —
Firm Address 5068 Avery, The Colony
Gauge # 372461
Date last accuracy tested 03/03/13
Certified Tester Scott Masdon
Cent. Tester No. 2524 Date 06/06/13
e
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V ACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed 2.2
Closed Tight ❑✓
Ctiped at
Opened at
nsid
—�
Tight [Z]
Leaked C
we ,psid
�_psid
RP- +,psid
Leaked Cl
2.4
Did not Open o
Leaked C
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
.,�tsid
Repair
Tight C
_,paid
psid
RP sid
The above is certified to be true.
Professional Backflow
Firm Name - _ -- —
Firm Address 5068 Avery, The Colony
Gauge # 372461
Date last accuracy tested 03/03/13
Certified Tester Scott Masdon
Cent. Tester No. 2524 Date 06/06/13
e
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy