2013_0823CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
,S 4
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
C % Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve a Atmosphere Vacuum Breaker
Manufacturer L4S Size
Model Number CA ;?00 Located At
Serial Number -E - 09u S'
The above is c1\eh�rdfied to be true.
Firm Name AN -;T
Firm kt \),wj
R- Wfr tic -1(0
Gauge # D(gc9'1 I'l V4
Date last accuracy tested D
Certified Tester VAL�^
Cert. Tester No. V001 7N(, Date �3 l
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
'ef Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
olClosed Tight
Opened at
Opened at
osid
Ti
Leaked ❑
nsid
osid
Ito
RP.psid
Leaked o
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
vsid
osid
RP sid
The above is c1\eh�rdfied to be true.
Firm Name AN -;T
Firm kt \),wj
R- Wfr tic -1(0
Gauge # D(gc9'1 I'l V4
Date last accuracy tested D
Certified Tester VAL�^
Cert. Tester No. V001 7N(, Date �3 l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy