2013_0204CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ki2—L,
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
i�
Manufacturer 3 ` Size 3%
Model Number 5�;o
Serial Number 1A Q- S Lo
Located At Rcy- �
The above is certified to be true.
Firm Name Nko,, Sj � �- Certified Testa i4e,3
Firm Address 20 Z L Cert. Testa No. TZ r a 'A3 a Date ll 3
-\-4- -7(a7-05
Gauge # 1 i o l c) LA O I(
Date last accuracy tested ;L- i - tb
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 2, 8
Closed Tight K
Opened at
Opened at
oSid
Tight
RP -_psid
Leaked � ❑
nsid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
osid
nSid
RP sid
The above is certified to be true.
Firm Name Nko,, Sj � �- Certified Testa i4e,3
Firm Address 20 Z L Cert. Testa No. TZ r a 'A3 a Date ll 3
-\-4- -7(a7-05
Gauge # 1 i o l c) LA O I(
Date last accuracy tested ;L- i - tb
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy