2013_0710CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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 C Pressure Vacuum Breaker
9/ Double Check Valve C Atmosphere Vacuum Breaker
J/
Manufacturer Size
Model Number v S 0
Serial Number / -� G / //
Located At 12 "- /. ( 0 ,<x� e K
The above is certified to be true. /
Firm Name 1qd 1 c w Certified Tester
Firm Address N). fi c) % `' 7 14're y)f ° Cast Tester No. 1��r1 �� r c; � Date 2
Gauge # 0,, U �' / / % `l 61
Date last accuracy tested ct S -/„�?
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
Tight
RP -_psid
Closed Tight ❑
Leaked 4(
Opened at
nsid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true. /
Firm Name 1qd 1 c w Certified Tester
Firm Address N). fi c) % `' 7 14're y)f ° Cast Tester No. 1��r1 �� r c; � Date 2
Gauge # 0,, U �' / / % `l 61
Date last accuracy tested ct S -/„�?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy