2013_0906 (22)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 backflow 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
zK Double Check Valve
Manufacturer 8D C,19:5
Model Number C 9
Serial Number �'f�%5 #.3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At Y / -
The above is certified to be true.
Firm Name
Firm Address',�� i�r <1✓1�:'v�%+
'2 '
Gauge #
Date last accuracy tested /e' 1,
Certified Tester-) C Y r C9 1
Cert. Tester No.'? „, Rr�l `f Date r/�
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 ❑
Leaked ❑
psid
osid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address',�� i�r <1✓1�:'v�%+
'2 '
Gauge #
Date last accuracy tested /e' 1,
Certified Tester-) C Y r C9 1
Cert. Tester No.'? „, Rr�l `f Date r/�
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy