2013_0426 (9)CHECK ONE:
IRRIGATION_,
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # �) (_) e
LOCATION OF SERVICE: <<%
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 0 Atmosphere Vacuum Breaker
Manufacturer bin .r 15 Size d
Model Number CO') 01 1 Located At ' 14,1 e Tc--- C),t
Serial Number A :� G 1,40
The above is certified to be true. Y *' S
Firm Name A c: -T"rt. +) C r C
Firm Address Pt) Ge,) x % 1
Gauge # L9 /
Date ]last accuracy tested 3113
Certified Tester 1A) v%Af1
Cat Testa No. O(Y) 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 AP
Opened at
Opened at
ttsid
Tight /, (7 do
Leaked r, ❑
Dsid
esid
RP- ._esid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
esid
RP sid
The above is certified to be true. Y *' S
Firm Name A c: -T"rt. +) C r C
Firm Address Pt) Ge,) x % 1
Gauge # L9 /
Date ]last accuracy tested 3113
Certified Tester 1A) v%Af1
Cat Testa No. O(Y) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy