2013_0906 (14)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: )o
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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number '� Located At Y
Serial Number
The above is certified to be true.
Firm Name / z- / OA M
Firm Address r64 'rl�rrG
7, 7�c55
Gauge # ? Zle ,� 5
Date last accuracy tested G' /e' f
Certified Tester ! �'
Cert. Tester IC7 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 -21-6Lpsid
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 ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name / z- / OA M
Firm Address r64 'rl�rrG
7, 7�c55
Gauge # ? Zle ,� 5
Date last accuracy tested G' /e' f
Certified Tester ! �'
Cert. Tester IC7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy