2013_0906 (21)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: f, ���G C. 1C/%/;C�. '/2
f
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.
Reduced Pressure Principle
❑ Double �Check Valve
Manufacturer
Model Number
Serial Number S 'S
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At_/
The above is certified to be true.
Firm Name Me y r-0 L bAlln
Firm Address
/ 76,09
Gauge #
Date Last accuracy tested P/
le A
Certified Testa f f 4 Y
Celt. Tester No. Date '!4
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- G sid
Leaked ❑
Leaked ❑
nsid
osid
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name Me y r-0 L bAlln
Firm Address
/ 76,09
Gauge #
Date Last accuracy tested P/
le A
Certified Testa f f 4 Y
Celt. Tester No. Date '!4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy