2013_0314 (4)CHECK ONE: \ /
IRRIGATION
DOMESTIC
FIRELINE
BACW'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: J ` P
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.
C Reduced Pressure Principle
t' Double Check Valve
Manufacturer
Model Number
Serial Numbet � / r, / 5
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
Firm Address LI yi;�- T�
Gauge # 0 /j L 0 7�-C'
Date last accuracy tested 1-/ / r-? -/ 2
Certified Testa
Cat. Tester No. .�P"
Date a _/ y
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 �,? .
Closed Tight 'd
Leaked /. Ca ❑
Opened at
osid
Opened at
�osid
nsid
RP -_-psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
flsid
�psid
RP sid
The above is certified to be true.
Firm Name
Firm Address LI yi;�- T�
Gauge # 0 /j L 0 7�-C'
Date last accuracy tested 1-/ / r-? -/ 2
Certified Testa
Cat. Tester No. .�P"
Date a _/ y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy