2013_0619CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
. ibo.)7 0/,j 1
OF
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
Manufacturer
Reduced Pressure Principle
Double Check Valve
Fr -6 eo
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
n
size /
Model Number 85 Located At MP 7L k �, W-
Serial Number
The above is certified to be true.
Firm Name 4ae'd 1t
Firm Address
Gauge #
Date last accuracy tested -/-/3
Certified Tester
Cert. Tester No. Date _3
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
Tight / S( ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP- id
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 4ae'd 1t
Firm Address
Gauge #
Date last accuracy tested -/-/3
Certified Tester
Cert. Tester No. Date _3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy