2013_0122 (30)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow 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
'St Double Check Valve
Manufacturer F7�=�C y
Model Numbers 7
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size l I
Located At A--- I ° e
The above is certified to be true.
Firm Name 94�,a c �1& Certified Tester
Firm Address J4 Cat Tester No Dente
Gauge #3 7v2 3 5- 3
Date last accuracy tested f - v2 aP - % 3
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
Ti Is-
Closed Tight 1f_
Leaked ❑
Opened at
osid
Opened at
osid
osid
lJ
RP - cA, sid
Leaked ❑
'
Did not Open ❑
Leaked E3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_,_osid
RP sid
The above is certified to be true.
Firm Name 94�,a c �1& Certified Tester
Firm Address J4 Cat Tester No Dente
Gauge #3 7v2 3 5- 3
Date last accuracy tested f - v2 aP - % 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy