2013_0104 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: I.1 i;
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is catified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
11
Manufacturer I , 1A S Size I
Model Number �(xxr) L QT Located At L-1-1 41 ; q
Serial Number 9 `�
The above is certified to be true.
Firm Name A I 1 ;E(1
Firm Address c�. ., L, ; L4,c, , tt
c , I,. ,e) , TV 7: Gil
Gauge # r 11CD0 S 6-
Date last accuracy tested
Certified Tester 1�," -,
Cart. Testa No. Date I e �X}/
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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
oSid
RP -_ nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name A I 1 ;E(1
Firm Address c�. ., L, ; L4,c, , tt
c , I,. ,e) , TV 7: Gil
Gauge # r 11CD0 S 6-
Date last accuracy tested
Certified Tester 1�," -,
Cart. Testa No. Date I e �X}/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy