2013_0905 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:,�'T, /4 6 U
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.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number '1
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C, Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name /� %1 Y" o C6 err art .
Firm Address AM J,26,2 G
;rx 76 0 �4
Gauge # G 1 IV y U 9S d
Date last accuracy tested
Certified Tester V G r yi SC �UG/C
Cert. Tester No. 31OZ40 Date
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
nsid
Tight ❑
Leaked ❑
nsid
nsid
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 /� %1 Y" o C6 err art .
Firm Address AM J,26,2 G
;rx 76 0 �4
Gauge # G 1 IV y U 9S d
Date last accuracy tested
Certified Tester V G r yi SC �UG/C
Cert. Tester No. 31OZ40 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy