2013_0122CHECK ONE:
IRRIGATION DOMESTIC FIRELINE I/"-
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: E �Ct 16&7
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
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
.k
Size
Located At L t l y r-(- �-(
—_j
j
The above is certified to be true.
Firm Name n
Firm Address . ')a //c t.c' CK
_. J 5 �, le
3, ��
Gauge # `�i 7,2
Date last accuracy tested Z
Certified Tester Ale /' X / A
Cert. Test= No. f 16 `J7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
dal Tes
DC- Closed
Tight
RP -psid
Leaked
Closed Tight
Leaked
Opened at
nsid
Opened at
vsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
nsid
_____-.p sid
RP sid
The above is certified to be true.
Firm Name n
Firm Address . ')a //c t.c' CK
_. J 5 �, le
3, ��
Gauge # `�i 7,2
Date last accuracy tested Z
Certified Tester Ale /' X / A
Cert. Test= No. f 16 `J7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy