2013_0411 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 0 P >' �9N
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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
2( Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Size
Model Number � 0S i Located At
Serial Number 8l'C 4Dg l�
The above is certified to be true.
Firm Name WM I IRe
Firm Address 9 iPIQ 5
Gauge #
Date last accuracy tested 7! 1 �l
PRESSURE VACUUM BREAKER
Air Inlet Check Valve
Opened at nsid
nSid
Did not Open ❑ 1 Leaked ❑
Opened at I nsid
nSid
Certified Tester rqj c�) O,C
Cert. Tester No. �, -I t % Date i l 13
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Initial Test
DC- Closed
Tight 1,
RP -._ —psid
Closed Tight ❑
Leaked ❑
Opened at
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Repair
Tight ❑
psid
RP sid
The above is certified to be true.
Firm Name WM I IRe
Firm Address 9 iPIQ 5
Gauge #
Date last accuracy tested 7! 1 �l
PRESSURE VACUUM BREAKER
Air Inlet Check Valve
Opened at nsid
nSid
Did not Open ❑ 1 Leaked ❑
Opened at I nsid
nSid
Certified Tester rqj c�) O,C
Cert. Tester No. �, -I t % Date i l 13
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy