2013_0905 (14)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: e G ("n c r . c, 7J c Al ru 44,
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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
zi Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �? ? ' !.' S Size
Model Number Located At K/ S G ✓ nt j/v J:: f
Serial Number
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested i ,/' � r' A-9-
Certified Tester ' N
Cert. Tester No. OPT 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
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
RP- �, z psid
Leaked Cl
DSid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested i ,/' � r' A-9-
Certified Tester ' N
Cert. Tester No. OPT 9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy