2013_0906 (10)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 4(s n c a
The baclflow 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 ./, /%) & S
Model Number � ), - ` )(" l
Serial Number (. ,o / 5 / �C,
Size
Located At ./ ii'
The above is certified to be true.
Firm Name
Firm Address �-Ir / / L i (7-- rl, 4)U L ; /,I
Gauge #�
Date last accuracy tested � �L? /
Certified Tester K,,-,c4 —)C/ e
Cent. Taster 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 Cheri:
2nd Check:
Relief Valve
f Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight ❑
RP- sid
Leaked ❑
psid
osid
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
Firm Address �-Ir / / L i (7-- rl, 4)U L ; /,I
Gauge #�
Date last accuracy tested � �L? /
Certified Tester K,,-,c4 —)C/ e
Cent. Taster No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy