2013_0411 (24)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: wYj
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.
C Reduced Pressure Principle
^_ Double Check Valve
Manufacturer
Model Number
Serial Number R 3
TYPE OF ASSEMBLY
c Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At �'5E(�
The above is certified to be true.
Firm Name -T -1 N I V, r C
Firm Address Cy n Cn r S
t
Gauge #'� (7g
Date last accuracy tested '7/f V l
Certified Tester �A � C� r r 1 NY r ! r 4 P10
Cert. Tester No. �Pn () ! `1 a 17 Date 1411,113
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 o
Opened at
Opened at
osid
Tight ❑
Leaked o
osid
osid
RP- _psid
Leaked ❑
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name -T -1 N I V, r C
Firm Address Cy n Cn r S
t
Gauge #'� (7g
Date last accuracy tested '7/f V l
Certified Tester �A � C� r r 1 NY r ! r 4 P10
Cert. Tester No. �Pn () ! `1 a 17 Date 1411,113
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy