2013_0122 (7)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 dctailird below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
ManufacturerL
Model Number`''
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
n Atmosphere Vacuum Breaker
Size
Located At z" ,9, L a �, eg 4- t
The above is certified to be true.
Firm Name r
a ac�5 ek .
Firm Addrm,S74 Arnad
Gauge # 3-7 L 3 S- 3
Certified Tester �V � fi! 6Z;rldC'�l/
Ccrt. Tester Na ,Ne) 773 Date
Date last accuracy tested - - %!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
Ti_
Le
Leaked d sid ❑
Closed Tight 2-
Leaked ❑
Opened at
osid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name r
a ac�5 ek .
Firm Addrm,S74 Arnad
Gauge # 3-7 L 3 S- 3
Certified Tester �V � fi! 6Z;rldC'�l/
Ccrt. Tester Na ,Ne) 773 Date
Date last accuracy tested - - %!3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy