2013_0925CHECK 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 baclflow 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
'x Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number �.%'� Located At Lr�r�.���c� w�c �� �'�LC
Serial Number 1 4r, 1(. t
The above
�`is/certified to be true.
Firm NameT� cr
Firm Address s- i— dJ,,z, 7256 X10
Gauge #3 7d 3:5-3
Date last accuracy tested
C�
Certified Tester ,�C�2 c �����
Cat Tester No.6 toe)010 77 3 Date ' /,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
DC- Closed
Closed Tight ta,
Opened at
Opened at
osid
Tight !a
Leaked ❑
osid
osid
.psid
1 "
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
osid
osid
RP sid
The above
�`is/certified to be true.
Firm NameT� cr
Firm Address s- i— dJ,,z, 7256 X10
Gauge #3 7d 3:5-3
Date last accuracy tested
C�
Certified Tester ,�C�2 c �����
Cat Tester No.6 toe)010 77 3 Date ' /,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy