2013_0905 (4)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: A C I,
The baci low 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer T�f'i? I Size
Model Number %° Located At
Serial Number
The above is certified to be true.
Firm Name COQ Ivi
Firm Addcess
T7 760 9 5
Gauge #
Date last accuracy tested
Certified Tester -Te r r44
Cert. Tester No.)MrQ Y66,9 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 o
Opened at
Opened at
vsid
Tight, f El
RP -nsid
Leaked ❑
nsid
vSid
Lea;ed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nSid
vSid
RP sid
The above is certified to be true.
Firm Name COQ Ivi
Firm Addcess
T7 760 9 5
Gauge #
Date last accuracy tested
Certified Tester -Te r r44
Cert. Tester No.)MrQ Y66,9 Date -'
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy