2013_0819 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: I m'7-
The bacifflow 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
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer 4 Size
Model Number Located At
Serial Number
The above is certified to be true.
Firm Name
Firm Address 7 •-! 11"9 s '5 T
4/. �e 7Co
Gauge # /f /I _3 `/ G /
Date last accuracy tested
l f oCertified Tester
CerL Tester No. !!dins If 0 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check Z • 4
2nd Check Z.
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
osid
nSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address 7 •-! 11"9 s '5 T
4/. �e 7Co
Gauge # /f /I _3 `/ G /
Date last accuracy tested
l f oCertified Tester
CerL Tester No. !!dins If 0 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy