2013_0926CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 7 �'
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
e Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number _ii v Located At I`Y
Serial Number
The above is certified to be true.
Firm Name
Firm Address ✓ / �dL�J �,„ J;/
Gauge # Oa 2 LK Sd
Date last accuracy tested l>"" /—
Certified Testa v
Cent. Tester No. `ZPOd O V; O c I Date 7-- , -/
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- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm Address ✓ / �dL�J �,„ J;/
Gauge # Oa 2 LK Sd
Date last accuracy tested l>"" /—
Certified Testa v
Cent. Tester No. `ZPOd O V; O c I Date 7-- , -/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy