2013_0122 (18)CHECK ONE:
C 11%;1 CK1VV 4-j I
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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
SL
Double Check Valve
Manufacturer
ati t CJ' S
Model Number
Serial Number
1
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At I
The above is certified to be true.
Firm Name Certified Tester `Ma dc%ri
Firm Address a 4v Cent. Tester No �G Ca 7'7 3 Date %. 25, IS
Gauge # S 12 3
Date last accuracy tested 1-22 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 V�
Opened at
Opened at
osid
Tid lS
RP- opsid
Leaked ❑
C)
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
------.p sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Certified Tester `Ma dc%ri
Firm Address a 4v Cent. Tester No �G Ca 7'7 3 Date %. 25, IS
Gauge # S 12 3
Date last accuracy tested 1-22 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy