2013_0426 (5)CIIECK ONE:
1RR1GAT1ON__jQ
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: G(-)%
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
g) Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer WC-T-1 Size
Model Number �o`-) Located At
Serial Number A J
The above is certified to be true.
Firm Name A/ ii.,V CTLr�
Firm Address " (-' 6 w 9
Wc-x a h i•: C V1
Gauge # (,) 3 Coo j ) 1..q
Date last accuracy tested
Certified Tester NAk',4A4e, jJC"Nn "
Cert. Tester No. O JI l f3
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 -Clo ed
Tight I. e X
Closed Tight A
Leaked o
Opened at
osid
Opened at
nsid
nsid
RP -_psid
Leaked o
Did not Open 0
Leaked J
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ csid
Repair
Tight o
nsid
osid
RP sid
The above is certified to be true.
Firm Name A/ ii.,V CTLr�
Firm Address " (-' 6 w 9
Wc-x a h i•: C V1
Gauge # (,) 3 Coo j ) 1..q
Date last accuracy tested
Certified Tester NAk',4A4e, jJC"Nn "
Cert. Tester No. O JI l f3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy