2013_1204CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: T33 Qa If S,
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 C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer F c t Size ?/Ii"
Model Number ?'S0 Located At G� -F 'fowl
Serial Number
t,'C'7/ 566
The above is certified to be true.
Firm Name Certified Testa
Firm Addr= goo -75-s 4^ Cent. Testa No. ��?'�l fL Date - tl -t3
Gauge # 015/17 `e"
Date last accuracy tested
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 7. t
Leaked ❑
nsid
osid
RP- _,psid
Leaked C
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name Certified Testa
Firm Addr= goo -75-s 4^ Cent. Testa No. ��?'�l fL Date - tl -t3
Gauge # 015/17 `e"
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy