2013_1010CHECK ONE:
IRRIGATION )L
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
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturer t/ I " C Size
Model Number k.-!�. 0 Located At
Serial Number
F-/.; I /-
The above is certified to be true.
Firm Name 0 U i ,i / a Certified Tester �c. C 11/c,
Firm Address A-ui % I" Cent. Tester No. Z Z Date Cc� —1 c r 3
Gauge # 3 7 J '-I C'/
Date last accuracy tested / j ! 3
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
osid
Tight
Leaked D
osid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight
sid
nsid
I
RP -id
The above is certified to be true.
Firm Name 0 U i ,i / a Certified Tester �c. C 11/c,
Firm Address A-ui % I" Cent. Tester No. Z Z Date Cc� —1 c r 3
Gauge # 3 7 J '-I C'/
Date last accuracy tested / j ! 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy