2013_0122 (37)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE K
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
Double Check Valve
Manufacturer
Model Number
Serial Number 1 k C � �,
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true. f� /
Firm Name 0 c Certified Testa
Firm A N OCat. Testa No �1aD�C� '7 73 Date
Gauge # 3 7,,)3,5- 3
Date last accuracy tested /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
-
DC- Closed
Tight 81
DSid
I,�;ed Cl
Closed Tight Q4
Leaked ❑
Opened at
nSid
Opened at
nSid
Did not Open ❑
DSid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__paid
Repair
Tight ❑
nSid
DSid
RP sid
The above is certified to be true. f� /
Firm Name 0 c Certified Testa
Firm A N OCat. Testa No �1aD�C� '7 73 Date
Gauge # 3 7,,)3,5- 3
Date last accuracy tested /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy