2013_0611CHECK ONE:
IRRIGATION
DOMESTIC
FIR.ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 2()(0 if . 6kL7Lik)� ?CD gLt'.
The baclflow 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer WA-711 � Size
Model Number o� 7A4 2 Located At _N 8 I ))L Ai- m V',.
Serial Number 5l T
The above is certified to be true.
Firm Name I)Q/IIAI I k. aKAW
Firm Address X 55 PAC - —1y JF
Gauge # / C
Date last accuracy tested
�
Certified Testa j VWI Z ',$;�-) AJ-7
Cat. Testa No. 9P--tVbY� 13 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
RP -. pSid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
Sid
Did not Open C2
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
oSid
oSid
RP sid
The above is certified to be true.
Firm Name I)Q/IIAI I k. aKAW
Firm Address X 55 PAC - —1y JF
Gauge # / C
Date last accuracy tested
�
Certified Testa j VWI Z ',$;�-) AJ-7
Cat. Testa No. 9P--tVbY� 13 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy