2013_0528 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACCFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: w\�
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
VVA"iTS Size
1ML
1�-7i 1
Located At
The above is certified to be true. ,des
Firm Name D55 ' is e6uar'D Certified Testa Wl(rer � 5 Game Z
ty,,> rn+t.iXr 0..D
Firm Address oA t iA . Ti -15132r Cat. Testa No. $�'`` '� ` Date S 29-13
Gauge # 51111174
Date last accuracy tested 1 -7 -13
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
uSid
Tight ❑
Leaked ❑
nSid
uSid
RP _ _pSid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
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. ,des
Firm Name D55 ' is e6uar'D Certified Testa Wl(rer � 5 Game Z
ty,,> rn+t.iXr 0..D
Firm Address oA t iA . Ti -15132r Cat. Testa No. $�'`` '� ` Date S 29-13
Gauge # 51111174
Date last accuracy tested 1 -7 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy