2013_0104 (8)CHECK ONE:
IRRIGATION
DOMESTIC_ V"'_
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Qom: r k Tr : n k! r► r.
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
e Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer I a I- V1
Model Number L fr ODfi PG-G?
Serial Number COD '>S
Size
Located At A6L R t, zi
The above is certified to be true.
Firm Name A 11:, d -f ; ,,.e_
Firm Address ?, /' 0 -2-/-"
,T V 75c z
Gauge # -1►� aL� £s t�
Date last accuracy tested 3�/aU11�
Certified Tester �� ' ,% 1 ^140 11
Cert. Tester No. M)(. l 5 7 Date I t C i3
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
psid
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name A 11:, d -f ; ,,.e_
Firm Address ?, /' 0 -2-/-"
,T V 75c z
Gauge # -1►� aL� £s t�
Date last accuracy tested 3�/aU11�
Certified Tester �� ' ,% 1 ^140 11
Cert. Tester No. M)(. l 5 7 Date I t C i3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy