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CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
S . �1Qcar4 of �
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.
❑ Reduced Pressure Principle
r0"' Double Check Valve
Manufacturer F a c o
Model Number 9 o-7 !
Serial Number L K Z/ OD Z
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size I )-Z
Located At -r— 1 k F R I set K�00�j
The above is certified to be true.
Firm Name J 04 / rj r t
Firm Address C #A 5- "
Gauge # 32,\709
Date last accuracy tested -71) ! �.
Certified Tester
Cert. Tester No. '��Q Date
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
osid
r,-A-�` E �
Tight ❑
RP -_ psid
Leaked ❑
Leaked ❑
psid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name J 04 / rj r t
Firm Address C #A 5- "
Gauge # 32,\709
Date last accuracy tested -71) ! �.
Certified Tester
Cert. Tester No. '��Q Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy