2013_0528 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
NkWy
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
a}/ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Wes_- Size
Model Number '774 Located At
Serial Number 116 %e0
ri d rk,
The above is certified to be true. ieS
Firm Name yss f: tRL-4wuarn
JOU-r do
Firm Address ► ^ -r `� s z 3 t''
Gauge # a /ii1rgt.
Date last accuracy tested ' -"%-
Certified Tester W�`
Cert. Tester No. 1pno, 3 0 9 � Date S'" 2,r -
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
nsid
Tight ❑
Leaked ❑
nsid
nsid
RP- L J Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
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. ieS
Firm Name yss f: tRL-4wuarn
JOU-r do
Firm Address ► ^ -r `� s z 3 t''
Gauge # a /ii1rgt.
Date last accuracy tested ' -"%-
Certified Tester W�`
Cert. Tester No. 1pno, 3 0 9 � Date S'" 2,r -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy