2013_0411 (27)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ID rhASC
A X
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
^_ Double Check Valve
Manufacturer h C
Model Number
Serial Number` n
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name TcA A ';�\ c C
Firm Address 2 nn C"
Gauge # % 2
Date last accuracy tested
N
Certified Testa "`' 4 f
Cert. Testa No. Y-""k' 1_1 417 Date 4 13
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 ❑
RP- _psid
Leaked C)
oSid
nSid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name TcA A ';�\ c C
Firm Address 2 nn C"
Gauge # % 2
Date last accuracy tested
N
Certified Testa "`' 4 f
Cert. Testa No. Y-""k' 1_1 417 Date 4 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy