2013_0104CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACEnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: L 1, —T 2, k 1! u 5 10 2S S.& 14 f;
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer [t-)t —II Size
Model Number M t Located At f,
Serial Number U ( a
The above is certified to be true.
Firm Name
Firm Address
Gauge # 01�,!
Date Last accuracy tested �,/l /001
Certified Tester
Cert. Testa No. FPM Ii) S -L Date I 2l 2v"3
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 ❑
Leaked ❑
Opened at
Dsid
Opened at
1. Ll sid
Dsid
lz -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
psid
Opened at
Dsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # 01�,!
Date Last accuracy tested �,/l /001
Certified Tester
Cert. Testa No. FPM Ii) S -L Date I 2l 2v"3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy