2013_0906 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 7� c
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
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
,d?.,.?�' S.
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
c Atmosphere Vacuum Breaker
Size 1
Located At It r rc ?.
The above is certified to be true.
Firm Name
Firm Address !'
.. 7�cU9
Gauge #
Date last accuracy tested •)" ),- // --?
Certified Tester
Cert. Testa No. 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 ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
F,P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address !'
.. 7�cU9
Gauge #
Date last accuracy tested •)" ),- // --?
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy