2013_0613 (8)CIIECK ONE:
IRRIGATIONN_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: g e), / Ay A /4 a'c'd
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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer a-.,, /'I j /,S
Model Number 00/
C
Serial Number ,& !; ? j
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C7 Atmosphere Vacuum Breaker
i/
Size 17
Located At - c c:) X �t e e
The above is certified to be true.
Firm Name )90 J�v A- f / X r
Firm Address 10 - I ) 1 17 W ^1X4,
Gauge # D to t-1 / 7 9 0
Date last accuracy tested q - S 7
Certified Tester %i A-- U/z /% i9
Cert. Tester No. 94900070 Date
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
Closed Tight ❑
Opened at
Opened at
psid
Tight ❑
Leaked ❑
psid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
�/
!
L�1/ j� le
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name )90 J�v A- f / X r
Firm Address 10 - I ) 1 17 W ^1X4,
Gauge # D to t-1 / 7 9 0
Date last accuracy tested q - S 7
Certified Tester %i A-- U/z /% i9
Cert. Tester No. 94900070 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy