2013_0411 (5)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: Id -�V kM
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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Ft BC o Size �2
Model Number IZ 0 5 Y Located At F'i k R CYZ) in
Serial Number R k 3 9 5 �o
The above is certified to be true.
Firm Name ' ' l� IZ t
Firm Address � q �`� CARP � I
Gauge #
Date last accuracy tested
Certified Testa
Cat Testa No.Ill'40 I Date I t
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 (2t
Leaked ❑
nsid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
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 ' ' l� IZ t
Firm Address � q �`� CARP � I
Gauge #
Date last accuracy tested
Certified Testa
Cat Testa No.Ill'40 I Date I t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy