2013_0906 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: )1C,,
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
n
Manufacturer
Model Number
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve M Atmosphere Vacuum Breaker
Size
Serial Number CY7
Located At
The above is certified to be true.
Firm Name 1—,qB 1` Yn Co m m
Firm Address I°D/41 ?6 Z Cyy-& aawz,6; '
7x , 760 � I
Gauge # Q Y ®ye �Q
Date last accuracy tested lj
-T Certified Tester P. Y Leo Sc f?06
CerG Tester NodZdaLX �ZDate
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- sid
Leaked ❑
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
tssid
osid
RP sid
The above is certified to be true.
Firm Name 1—,qB 1` Yn Co m m
Firm Address I°D/41 ?6 Z Cyy-& aawz,6; '
7x , 760 � I
Gauge # Q Y ®ye �Q
Date last accuracy tested lj
-T Certified Tester P. Y Leo Sc f?06
CerG Tester NodZdaLX �ZDate
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy