2013_0628CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC3CFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
❑ Reduced Pressure Principle
¢( Double Check Valve
Manufacturer co
Model Number -650
Serial Number 4 l l7
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
ik
Size
Located At KAwr ia. '2 t.nU
The above is certified to be true.
Firm Name M 6 14/.Z Certified Tester
Firm A T a Cat Tester No. �1 Date 13
�, I1�r yo —1(j;H {'
Gauge # 0 -)n8q
Date last accuracy tested Z
Yellow - City Copy
White - Customer's 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
'tial Test
DC- CloseQ,0
Tight
Closed Tight
Leaked ❑
Opened at
nsid
Opened at
nSid
nsid
l�
a"
_
RP- .psid
Leaked ❑
a '
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test Auer
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name M 6 14/.Z Certified Tester
Firm A T a Cat Tester No. �1 Date 13
�, I1�r yo —1(j;H {'
Gauge # 0 -)n8q
Date last accuracy tested Z
Yellow - City Copy
White - Customer's Copy
Pink - Tester's Copy