2013_1011 (9)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Z/ / /bc
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable per.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
, ►e Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer i(AIX&I Size
Model Number �� ! "� Located At rA Srf t l�
Serial Number •� P5�1-'6
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Rye{ Valve
Air Inlet
Check Valve
1st Check
tad Check /-4-
Initial Test
DC- Closed
Closed Tight
Opined at
Opened at
� id
Tight U31,
Leaked ❑
�psid
.paid
RP _psid
Leaked ❑
Did not Open ❑
Lra W- D
��
and
Materials
Used
Test Ai%r
DC- Closed
Closed Tight o
Opined at
Opened at
�psid
Repair
Tight ❑
� d
___psid
RP
The above is certified to bevue.
fj /
Firm Name � �'^- f'r''� �� Certised Tester 4,rl n
Firm Address r- %7 :9 Vv- Cent. Tester No. & 9,0*0 /5-'7 Dace
PJ —?o -75,.- 7S lb 9
Gauge # o-7 9t> 4 d'$
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy