2013_0906 (19)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
r
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer /?'1 S Size
Model Number U e
Serial Number 1�11 �c (� S
Located At 4, i S �,, e i
The above is certified to be true.
Firm Name 4 4W —
Firm Address A! eeI16
7, -2(sr%`l
Gauge #
Date Last accuracy tested 1 {�
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight ❑
RP-�sid
Leaked Cl
Dsid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 4 4W —
Firm Address A! eeI16
7, -2(sr%`l
Gauge #
Date Last accuracy tested 1 {�
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy