2013_0906 (11)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:; !� - i1r 14 b 14
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.
C
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At J /",
The above is certified to be true.
Firm Name 1 J27 Y � r, 0,0-71A'9
Firm Address r,1/
Gauge #
Date last accuracy tested //' //0
/
Certified Tester` G Y
Cert. Tester No.. G 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 Z'
RP- �)„psid
Leaked ❑
Leaked 13
osid
osid
Did not Open ❑
Leaked ❑
Reps
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 1 J27 Y � r, 0,0-71A'9
Firm Address r,1/
Gauge #
Date last accuracy tested //' //0
/
Certified Tester` G Y
Cert. Tester No.. G Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy