2013_0613 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
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 Reduced Pressure Principle
X Double Check Valve
Manufacturer L * � -"
Model Number U ® 7 -f /
Serial Number 4" c 6 z
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size /v
Located At
The above is certified to be true.
Firm Name
Firm Address 7 7 lk4 )w
Gauge # c',' & 0 V1 7 Y&
Date last accuracy tested `% S /
e ,r
Certified Tester
r6ert. Tester No. ' *��?G' , 10 Dace
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 3
Closed Tight <
Leaked ,? ❑
Opened at
t?sid
Opened at
esid
esid
RP- Dsid
Leaked ❑
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
esid
Repair
Tight ❑
Dsid
Dsid
M=====P—Sid
The above is certified to be true.
Firm Name
Firm Address 7 7 lk4 )w
Gauge # c',' & 0 V1 7 Y&
Date last accuracy tested `% S /
e ,r
Certified Tester
r6ert. Tester No. ' *��?G' , 10 Dace
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy