2013_0122 (13)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
IL Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 41yk size
Model Number Located At 1 11 L v1
Serial Number 0 S
The above is certified to be true.
Firm Name f,,41,I) 0 Certified Tester
Firm Address V'Jy-' dziad—jol -7-roelc) Cat Tester Na &010773 Date 9',95-1,3
Gauge # J 7 2,3 S-3
Date last accuracy tested /, cRa - 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
i-�5LD
DC-Closed
Tight , 2-�
Ri-_LLpsid
Leaked
Closed Tight Q
Leaked C3
Opened at
Sid
Opened at
psid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
psid
nsid
RP======2sid-
- -
The above is certified to be true.
Firm Name f,,41,I) 0 Certified Tester
Firm Address V'Jy-' dziad—jol -7-roelc) Cat Tester Na &010773 Date 9',95-1,3
Gauge # J 7 2,3 S-3
Date last accuracy tested /, cRa - 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy