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CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC) FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: '`7... , L%` ^ L I( t r.,5 IU-)S —e> �,,1+ 1, c H.)lY>
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
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
^_ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer " t L, Size
Modei Number � )r0t1 Q 1
Serial Number
Located At
The above is catified to be true.
Firm Name
Firm Ad&= o? 3 111sa, di
Gauge # 091('x(, SlP
Date Last accuracy tested
Certified Tester S I e 5 /9. 6 sec. ,
Cent. Tester No. Rk. b r < -7 S- Date L i''
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
nsid
Opened at
vsid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
psid
vsid
RP sid
The above is catified to be true.
Firm Name
Firm Ad&= o? 3 111sa, di
Gauge # 091('x(, SlP
Date Last accuracy tested
Certified Tester S I e 5 /9. 6 sec. ,
Cent. Tester No. Rk. b r < -7 S- Date L i''
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy