2013_0411 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: lino S _ �C��0c �v�
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 par=eters.
TYPE OF ASSEMBLY
rC� Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer F66(, o Size
Model Number - 0,5'
Serial Number A on 91.
.. •iii
The above is certified to be true.
Firm Name J df�9 1- 191
Firm Address 7 9 0 9 C�iK k S.
Tx
Gauge # :;� 72, 1 7 HZ'S
Date last accuracy tested 7 /1 u, 1.!
Certified Tester (�� tC\f\C� f
Cent Tester No. Q�� "T7 ' Date !,A)/13
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 ❑
osid
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 ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name J df�9 1- 191
Firm Address 7 9 0 9 C�iK k S.
Tx
Gauge # :;� 72, 1 7 HZ'S
Date last accuracy tested 7 /1 u, 1.!
Certified Tester (�� tC\f\C� f
Cent Tester No. Q�� "T7 ' Date !,A)/13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy