2013_0122 (23)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE Y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: E-5 /L�'J7
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
P..4 Double Check Valve C Atmosphere Vacuum Breaker
!ti'1. �:
Manufacturer Size I
Model Number c�
Located At T11 k( c .camC
Serial Number 1 L 03 �_
The above is certified to be true. _
Firm Name
Firm Address C- cirICA- d -rc -7 5--D 1/ v
Gauge # 3 70 3 S 3
Date last accuracy tested / - 13
Certified Tester 7ya "7 I'1 C56? nC z)0a j
Cert. Testa No. ,� GO/ d 7 Date 2,22--LS
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 f9-
Opened at
Opened at
oSid
t
Tight, M
Sid
Leaked ❑
Leaked ❑
vSid
oSid
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true. _
Firm Name
Firm Address C- cirICA- d -rc -7 5--D 1/ v
Gauge # 3 70 3 S 3
Date last accuracy tested / - 13
Certified Tester 7ya "7 I'1 C56? nC z)0a j
Cert. Testa No. ,� GO/ d 7 Date 2,22--LS
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy