2013_0906 (12)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 1: Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number � rS LJ-,!? _
Size
Located At i''/ S 'y eez
The above is certified to be true.
Firm Name
Firm Address ' LIM
Gauge #�� C
Certified Tester
n/ Cert. Tester No. Date
Date last accuracy tested f' Lh,�
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
nSid
Tight ❑
Leaked ❑
nSid
nSid
RP -_psid
Leaked o
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address ' LIM
Gauge #�� C
Certified Tester
n/ Cert. Tester No. Date
Date last accuracy tested f' Lh,�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy