2013_0613 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D.
LOCATION OF SERVICE:'
The bacltilow 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
t Double Check Valve G Atmosphere Vacuum Breaker
,f
Manufacturer
I/ A T / 7
Size
9
Model Number
-7 Ll X
Located At
C° e, it vi- ek
Serial Number / 0 (r' "'� G% /
The above is certified to be true.
Firm Name %. �i �ti l // a Certified Tester /` -
Firm Address /��:' X ry-
ert. Tester No. fJ l0 -000 &A Date
Gauge #x) G 0 y/ 15;1 p
Date Last accuracy tested
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 Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
nSid
Tight - 0 ❑
Leaked
nsid
nSid
RP- __psid
Leaked
Did not Open o
Leaked C3
Repairs
and
Materials
Used
Test Altar
DC- Closed
Closed Tight o
Opened at
Opened at
_ nsid
Repair
Tight 13
nSid
nSid
RP sid
The above is certified to be true.
Firm Name %. �i �ti l // a Certified Tester /` -
Firm Address /��:' X ry-
ert. Tester No. fJ l0 -000 &A Date
Gauge #x) G 0 y/ 15;1 p
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy