2013_0308 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE C
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ;7C' C` G'- /; I / e.
The bacl&ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
, 4i�s
C' G -i
Serial Number 12'L 7�v!s
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere_ Vacuum Breaker
Size
Located At �l i c /'/
The above is certified to be true.
Firm Name 4 c 11 b I ``'` Certified Tester 7'f`
Firm Address 7 `/ 7 Cert. Tester No. ��G'`"�` ` Date
Gauge # 6)&0 c/ 1,7 �L'
Date last accuracy tested ''T- /,) °/,)
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 /, y
Tight X
Closed Tight 0(
Leaked / , `/ ❑
Opened at
osid
Opened at
_osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
----p sid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 4 c 11 b I ``'` Certified Tester 7'f`
Firm Address 7 `/ 7 Cert. Tester No. ��G'`"�` ` Date
Gauge # 6)&0 c/ 1,7 �L'
Date last accuracy tested ''T- /,) °/,)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy