2013_1101CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer /00 S Size
Model Number 77y ���� Located At �rr
Serial Number
The above is certified to be true.
Firm Name W e51erQN 54o Certified Testa
Firm Address ? 4J• Al I'W /yc�, % Cert Testa No. �3f�/ Date
Gauge # Of5/0 /l ."'G
Date last accuracy tested
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
U�.
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
RP - �i -Z-- psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
flsid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name W e51erQN 54o Certified Testa
Firm Address ? 4J• Al I'W /yc�, % Cert Testa No. �3f�/ Date
Gauge # Of5/0 /l ."'G
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy