2013_1017CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer ckr-,
Model Number '� CLnP __at`
Serial Number ALA 1 i Z
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name Y, `SAM W Certified Tester _Tnt:F \ 11 v-cl
Firm Address {_�C _�'c�►1 Y1�, W1> . Cert. Tester No. WMM71 Date
Gauge # _ t 1 `A N10
Date last accuracy tested 1 r"
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 ❑
RP -, . Dsid
Leaked ❑
osid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name Y, `SAM W Certified Tester _Tnt:F \ 11 v-cl
Firm Address {_�C _�'c�►1 Y1�, W1> . Cert. Tester No. WMM71 Date
Gauge # _ t 1 `A N10
Date last accuracy tested 1 r"
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy