2013_0104 (14)CHECK ONE:
IRRIGATION
DOMESTIC 1/1
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: k 14 1;
The baclflow 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 ❑ Atmosphere Vacuum Breaker
Manufacturer "ff-S Size
Model Number 8(X M Ll &T
Serial Number ",I () 330
Located At _eve ec kor H
The above is certified to be true.
Firm Name AA,d 471, Pd- fc�rvr�
Firm Address m ; +t- -9,3a_
66" k "cl , rx -2501.1
Gauge # 1 Ua /: t,-
Date last accuracy tested
Certified Tester 6 All.
Cert. Tester No. R P! �e 1,) S ? S Date _ ! 1 L I ,A 1 r 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
psid
Opened at
i . LI nsid
psid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name AA,d 471, Pd- fc�rvr�
Firm Address m ; +t- -9,3a_
66" k "cl , rx -2501.1
Gauge # 1 Ua /: t,-
Date last accuracy tested
Certified Tester 6 All.
Cert. Tester No. R P! �e 1,) S ? S Date _ ! 1 L I ,A 1 r 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy