2013_1024 (5)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baci low 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 a Pressure Vacuum Breaker
c Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer V\ ti Qs, l Size t
Model Number �) > C - 7T Located At k,� ,w S kki 4 "�`�3h • 1y1 ULT
Serial Number
The above is certified to be true.
Firm Name
Firm Address kk27i CCA L L W \).
3Z kA hk o(A � 77
Gauge # � LAOS M � T
Date last accuracy tested \ "2 L5 2-
Certified Tester ' SAS 1 )C \-Con
Cent. Tester No. 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
nsid
Tight o
Leaked ❑
nsid
nsid
Leaked O
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address kk27i CCA L L W \).
3Z kA hk o(A � 77
Gauge # � LAOS M � T
Date last accuracy tested \ "2 L5 2-
Certified Tester ' SAS 1 )C \-Con
Cent. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy