2013_0905 (17).4`.,?
CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: "6c°ns14 .>� . L, .�� ✓°,,�G',�/, < `.A,
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 hl'-n S
Model Number '(��
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name f() &M/y,
Firm Address PM% e ',
7 �GCy9
Gauge #
Date last accuracy tested
Certified Tester -t ko
Cert. Tester No.'��:" �/ �' Data
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,-) t ❑
RP -_psid
Leaked ❑
Leaked ❑
osid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name f() &M/y,
Firm Address PM% e ',
7 �GCy9
Gauge #
Date last accuracy tested
Certified Tester -t ko
Cert. Tester No.'��:" �/ �' Data
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy