2013_0411 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 1 dG j�1RCa�u—IX
`PPf
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
CReduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer t L O Size i �a
Model Number i Located At R F:
Serial Number _ k -2 `{
The above is certified to be true.
Firm Name
Firm Address NO r AP R S
Gauge # 7
Date last accuracy tested i,/( U /IoZ
Certified Tester M1 (1AC,1E M(Ck(A�A'1j
Cert. Tester No.'6001 ti 91 Date14 / (=
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
Tight ❑
RP -psid
Leaked ❑
Closed Tight ❑
Leaked ❑
g
Opened at
Dsid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address NO r AP R S
Gauge # 7
Date last accuracy tested i,/( U /IoZ
Certified Tester M1 (1AC,1E M(Ck(A�A'1j
Cert. Tester No.'6001 ti 91 Date14 / (=
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy