2013_0411 (14)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: tiRC o r� kv� �) v�
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Manufactured.
Model Number S() J ,r
Serial Number IIP91 �r-.4 W3
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 1 f/D
Located At t A V
The above is certified to be true.
Firm Name Certified Tester
Firm Address ! q 2' Cert. Tester No. `�? 'l''b 917 Date 1
Gauge #
Date last accuracy tested
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 o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester
Firm Address ! q 2' Cert. Tester No. `�? 'l''b 917 Date 1
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy