2013_0905 (15)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
((r?dt
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.
e Reduced Pressure Principle
❑ Double Check Valve
Manufacturer n �—
Model Number
Scrial Number 0 J, �
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphcre Vacuum Breaker
Size
Located At K/
The above is certified to be true.
Firm Name /) /e r,(U 0111 0)
Firm Address 19' 'W-to 26 "evril C
, ;t 7 �-Co 1
Gauge # r5O
Date last accuracy tested Y-' Ac
Certified Testa
Cat. Testa 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 e
Opened at
Opened at
oSid
Ti 13
RP -.:t psid
Leaked ❑
Leaked 13
Sid
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 /) /e r,(U 0111 0)
Firm Address 19' 'W-to 26 "evril C
, ;t 7 �-Co 1
Gauge # r5O
Date last accuracy tested Y-' Ac
Certified Testa
Cat. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy