2013_0104 (12)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: r k l
The bac0ow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer " H 5 Size 3/,- I "
Model Number U: -C rd PG OT Located At Akw,L tx,
Serial Number Woi3Lo
The above is certified to be true.
Firm Name Alec,,.( -T ; ,1
Firm Address r try -?SCLI
Gauge # Cc, I Uay b U
Date last accuracy tested 3 aU I a
Certified Tester C,,.c s /Yi,
CerL Tester No. &PtV L:)5 -7S Date 0 6X2/
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
_ i-I_ Sid
Tight C
Leaked ❑
pSid
i - a psid
RP -_ DSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
pSid
Repair
Tight ❑
psid
DSid
RP sid
The above is certified to be true.
Firm Name Alec,,.( -T ; ,1
Firm Address r try -?SCLI
Gauge # Cc, I Uay b U
Date last accuracy tested 3 aU I a
Certified Tester C,,.c s /Yi,
CerL Tester No. &PtV L:)5 -7S Date 0 6X2/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy