2013_0411 (10)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
CATION OF SERVICE: d 4 NS*)j r 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 parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer �BCU Size p
Model Number J 1 Located At rt l It i 5 E' 6
Serial Number 13 K 39 -7 O
The above is certified to be true.
Firm Name
Finn Address 79 G?9 C 14 k 1Z
Gauge #
Date last accuracy tested 7,% t_ ll ,
Certified Tester �` I M(C k I �vj
Cert. Tester No. ' x)17 DateV V13
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
Tight ❑
Leaked ❑
Dsid
osid
RP - _psid
Leaked ❑
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
Finn Address 79 G?9 C 14 k 1Z
Gauge #
Date last accuracy tested 7,% t_ ll ,
Certified Tester �` I M(C k I �vj
Cert. Tester No. ' x)17 DateV V13
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy