2013_0710 (3)CHECK 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.
C
1z
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number `1 eg f .3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
I'r
Size
Located At �%C,��', - I c t ^ ,�- �1r1dq
The above is certified to be true.
Firm Name 1� -1 r el x.- l' / Certified Tester i/ % � G %! y� s
Firm Address I tL %� A -7 `l 7 L' ✓;r ��- ��Ca t. Testa No.1- ��a �c > z Date 7 -/ a �•'
Gauge # G�( o ,/ l 7 �°v
Date last accuracy tested `--/ - 1_.;5r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight 6r
Closed Tight K
Leaked ❑
Opened at
nsid
Opened at
nsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened
Opened at
nsid
Repair
Tight ❑
Lpsid
vsid
RP sid
The above is certified to be true.
Firm Name 1� -1 r el x.- l' / Certified Tester i/ % � G %! y� s
Firm Address I tL %� A -7 `l 7 L' ✓;r ��- ��Ca t. Testa No.1- ��a �c > z Date 7 -/ a �•'
Gauge # G�( o ,/ l 7 �°v
Date last accuracy tested `--/ - 1_.;5r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy