2013_0906 (18)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE.-' 4 .L . �644
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 C Atmosphere Vacuum Breaker
Manufacturer !``�i7tC� S Size
Model Number 4 UDU 1-3 Located At
Serial Number Z :L.L�
The above is certified to be true.
Firm Name »,
Firm Address `'?/3 J-26 2 V
Tx -2 CC C,1
Gauge #
Date last accuracy tested
Certified Testa a Y Y cl -
Cat. Testa No. rf>>�� rf'� G 9 Date �1=
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 ❑
oSid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight o
osid
oSid
RP sid
The above is certified to be true.
Firm Name »,
Firm Address `'?/3 J-26 2 V
Tx -2 CC C,1
Gauge #
Date last accuracy tested
Certified Testa a Y Y cl -
Cat. Testa No. rf>>�� rf'� G 9 Date �1=
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy