2013_0906 (27)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1214 Z)c� i, I7f
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 C Pressure Vacuum Breaker
C Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer ¢i'I e S Size
Model Number S Located At r
Serial Number
The above is certified to be true.
Firm Name
Firm Address 'P 11'131,Z6 %G K,- L Ul '
7"1 iUG 9�
Gauge #
Date last accuracy tested !l' /O
Certified Tests„
Cert. Tester No.�1'i tC��Pr %; 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
nSid
Tight ❑
Leaked ❑
nsid
nSid
PIP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address 'P 11'131,Z6 %G K,- L Ul '
7"1 iUG 9�
Gauge #
Date last accuracy tested !l' /O
Certified Tests„
Cert. Tester No.�1'i tC��Pr %; Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy