2013_0819 (3)WT 'W-
CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly detailed 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
Manufacturer ��� rF-S
Model Number 1W 1 Cr T
Serial Number 5 c� S 2
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
2 i!
Located At env r•
The above is certified to be true.
Firm Name R c r T
Firm Address �I /O V
y, ry 71, o �i
Gauge # / e /
Date last accuracy tested
Certified Tester
Cert. Tester No. hI'r r, i 3 / o Date
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
osid
Tight ❑
RP -_psid
Leaked ❑
Dsid
osid
A S 3
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name R c r T
Firm Address �I /O V
y, ry 71, o �i
Gauge # / e /
Date last accuracy tested
Certified Tester
Cert. Tester No. hI'r r, i 3 / o Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy