2013_0208 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: S4) 0 � F Pa �' �� w y•
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 a Pressure Vacuum Breaker
P �
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 'o size 3
r�
Model Number Located At .0 r> E 49w' Xrrr Lv:LV
Serial Number
The above is certified to be true.
Firm Named Sr sTF�s, -`y"� Certified Tester
elrot z- I°i
Firm Address ?S1 l09'� sT• A1 ,11VvNi ;RCert. Testy No. BP- 001 -1 ,y 0 Date
Gauge # ®C 2 a-, Y I/
Date last accuracy tested 7.- 4— 7-,o /_?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
70A j 3
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight d
Opened at
Opened at
nsid
Tight Tr
RP- sid
Leaked o
Leaked ❑
nsid
nsid
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Named Sr sTF�s, -`y"� Certified Tester
elrot z- I°i
Firm Address ?S1 l09'� sT• A1 ,11VvNi ;RCert. Testy No. BP- 001 -1 ,y 0 Date
Gauge # ®C 2 a-, Y I/
Date last accuracy tested 7.- 4— 7-,o /_?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy