2013_0905 (9)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer z ? U,2 S Size
Model Number 0 6) Located At � � ✓ f'(�n� �� ���
Serial Number 5 ?5
The above is certified to be true.
Firm Name (T '?//s'!
Firm Address
?Go5%
Gauge # 0 ;�rG 1-14 j S U
Date last accuracy tested le le ;
Certified Testert?
Cert. Tester No. /?/'*1' /7 966 9 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
Ininal Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
---psid
Tight ❑
RP-
Leaked C1
psid
oSid
.,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name (T '?//s'!
Firm Address
?Go5%
Gauge # 0 ;�rG 1-14 j S U
Date last accuracy tested le le ;
Certified Testert?
Cert. Tester No. /?/'*1' /7 966 9 Date `
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy