2013_0122 (5)CHECK 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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
15t Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer a- o"'lC 5° Size � z
Modes Number r�ccc � Located At , f CLc C� .
Serial Number f, i D07
The above is certified to be true.. (�
Firm Name c 7 d� 0-L Certified Tester �t2 �. ) � ciaz czy
Firm Address o J a4--7d J4 -75-b 541 Cat Tester No. 666010 -1 -13 Date
Gauge # -3-7 9 3 S 3
Date last accuracy tested • -4 a 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 Q
Opened at
Opened at
osid
Tight 2S
Leaked ❑
psid
osid
RP- ILL osid
Leaked ❑
Did not Open O
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.. (�
Firm Name c 7 d� 0-L Certified Tester �t2 �. ) � ciaz czy
Firm Address o J a4--7d J4 -75-b 541 Cat Tester No. 666010 -1 -13 Date
Gauge # -3-7 9 3 S 3
Date last accuracy tested • -4 a 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy