2013_0122 (9)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 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
T Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At el cl- r��t_.
r ,\J
serial Number
The above is certified to be true.
Firm Name& Cc
Film Address'? n L r� �Sb eFo
Gauge # 5-1 Z3 S 3
Date last accuracy tested /.,-)0'13
Cent. Testa No. -7 13 Date Ct . ,) S ` 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 t
Opened at
Opened at
nsid
Tight.
Leaked ❑
nsid
nsid
t- j-
RP- I �: Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name& Cc
Film Address'? n L r� �Sb eFo
Gauge # 5-1 Z3 S 3
Date last accuracy tested /.,-)0'13
Cent. Testa No. -7 13 Date Ct . ,) S ` 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy