2013_0906 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: } dC 14 L 1�
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
Model Number Q !
Serial Number
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At ° / 'i �,, i,6 &,/1 t �
The above is certified to be true.
Firm Name , Ale iy-d cow,/0-7
Firm Address /3 /i i l r ✓c,��^Z�� r1 P
Gauge # j9 ,.: !/U 256
Date last accuracy tested
Certified Tester - Y Y l SC "#'7'9,0
Cart. Tests No.,gez erefl G q 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
Tight ❑
RP--2. sid
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
flsid
osid
RP sid
The above is certified to be true.
Firm Name , Ale iy-d cow,/0-7
Firm Address /3 /i i l r ✓c,��^Z�� r1 P
Gauge # j9 ,.: !/U 256
Date last accuracy tested
Certified Tester - Y Y l SC "#'7'9,0
Cart. Tests No.,gez erefl G q Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy