2013_0426 (3)CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. k
LOCATION OF SERVICE: `� C� v i C1 -v* 11%
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 C Atmosphere Vacuum Breaker
Manufacturer OLT-' S Size c9
Model Number 00'7 W i Located At i `'= y1,1 e ' r C, 't► tile' '� 5 i at C-
Serial Number A b d T
The above is certified to be true. I --'
Firm Name ,.�� ��� ^J'
Firm Address 00 Q� '7 C %
W, >6,r& "C-, t 1A -, G
Gauge #
Date last accuracy tested 3�/ l
Certified Tester 14)e-A tin
Cert. Testa No. � �+/ S! Date C- 0 1-/1.3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
god Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight /,a t
Closed Tight 0
Leaked L ❑
Opened at
esid
Opened at
esid
esid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__esid
Repair
Tight ❑
osid
esid
RP s'A
The above is certified to be true. I --'
Firm Name ,.�� ��� ^J'
Firm Address 00 Q� '7 C %
W, >6,r& "C-, t 1A -, G
Gauge #
Date last accuracy tested 3�/ l
Certified Tester 14)e-A tin
Cert. Testa No. � �+/ S! Date C- 0 1-/1.3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy