2013_1011CHECK ONE:
IRRIGATION
DOMESTIC FIAELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 0 0—
The backflow prevention assembly detailed below has been tested and maiataind as required by TNRCC
regudations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
e Reduced Pressure Principle
Double Check Valve
0 Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Manufacturer ls!/
Size
Model Number
Located At t Cc---) xe "-
Serial N=ber
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BR--.KER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check j.
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
--ps id
Tight
Leaked
a
�psid
— sid
RP -__---psid
Leaked 0
Did not Open o
Leaked 0
Reps
and
Materials
Used
Test After DC- Closed Closed Tight
0 Opened at Opened at �gsid
Repair Tight 0
d _,nsid
RF
The above is certified to be true.
Fm Name
Certified Tester r, n V-,/-
Firm Addc+eas Pa 8 7 9'-7
Cent. Tester No. Maft b I SE Date /.3
Gauge # 0-7. 9z>,4 ,?$
Date last accuracy tested !' l - 1.�. -t'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy