2013_0411CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: , Y( j(\\
The back-.low 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer F C �60 Size
Model Number 8050V Located At K 5 K l 0o h
Serial Number LJ 7 65-a . /
The above is certified to be true.
Firm Name T4 �\ C
, n I-t
Firm Address C4S �{
Gauge # �r
Date last accuracy tested 711
Certified Tester M j C� C� t I M-, (\ (- r �A 0
Cert. Tester No.�40 )1 U 11 7 Date q/1 + 43
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
flsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
psid
RP sid
The above is certified to be true.
Firm Name T4 �\ C
, n I-t
Firm Address C4S �{
Gauge # �r
Date last accuracy tested 711
Certified Tester M j C� C� t I M-, (\ (- r �A 0
Cert. Tester No.�40 )1 U 11 7 Date q/1 + 43
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy