2013_1212 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ' !S j S. pn, , � (" ,
The back-flow prevention assembly detailed below has been tested and maintained as required by MCC
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
Model Number
Serial Number % .3 - `� 157 fi I)
Size
Located At l/G 4
The above is certified to be true.
Firm Name Am Al,,- ,- Certified Testa i� k, 1161 ,1L -o C �
Firm Address -'f Cert. Testa No. `� P ``'' Date
Gauge # _01 D ( �
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
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
osid
nSid
RP- _nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name Am Al,,- ,- Certified Testa i� k, 1161 ,1L -o C �
Firm Address -'f Cert. Testa No. `� P ``'' Date
Gauge # _01 D ( �
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy