2013_0905 (8)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ' `i., r) fc
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer . /Im f .5
Model Number /1(
Serial Number s02/o/
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
;r
Size
Located At , ,! e '4, 0"'" 1
The above is certified to be true.
Firm Name [gym rV7. -
Firm Adds w /`%&-) (i7
7-x ?6c:
Gauge # �0
Date last accuracy tested G-'
Certified Tester
Cert. Tester 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
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
RP- Sid
Leaked ❑
psid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
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 [gym rV7. -
Firm Adds w /`%&-) (i7
7-x ?6c:
Gauge # �0
Date last accuracy tested G-'
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy