2013_0122 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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.
C Reduced Pressure Principle
X Double Check Valve
Manufacturer 6.�s
Model Number
Serial Number i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At -c--
The above is fcertified to be true.
Firm Name?" Q c dt Ua T
was CX,
Firm Address N2 JWU� TS`Ogo
Gauge # 3-7 0 3 5 3
Date last accuracy tested / 2 0 , /3
Certified Tester��Cin7�r/trZ
Cert. Tester No,6 EV C--1()-1-1'3 Date ct ' d S - 1,3
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
'a
DC- Closed
Tight fi
D�4 psid
Leaked ❑
Closed Tight Ot
Leaked ❑
C '
Opened at
osid
Opened at
nsid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
nsid
RP sid
The above is fcertified to be true.
Firm Name?" Q c dt Ua T
was CX,
Firm Address N2 JWU� TS`Ogo
Gauge # 3-7 0 3 5 3
Date last accuracy tested / 2 0 , /3
Certified Tester��Cin7�r/trZ
Cert. Tester No,6 EV C--1()-1-1'3 Date ct ' d S - 1,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy