2013_0905 (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: C .%� �� ��� -�/� is r�r1� i'c�/G' /,S'
The backflow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer`'" ' Size
Model Number - r G' 0 mr Located At ''I ; Y
Serial Number
The above is certified to be true.
Firm Name - � P �j'/. % rYlr=
Firm Addressl /2
7rx
Gauge # X, 5 E-1
Date last accuracy tested
Certified Tester
Cat Tester No.iJl`%' %'' c/ 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
osid
Tight ., L ❑
R Sid
Leaked o
osid
oSid
Leaked ❑
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
oSid
RP sid
The above is certified to be true.
Firm Name - � P �j'/. % rYlr=
Firm Addressl /2
7rx
Gauge # X, 5 E-1
Date last accuracy tested
Certified Tester
Cat Tester No.iJl`%' %'' c/ Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy