2013_0201CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE l%
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: '� f & X NSF -P—,
iii 7- 7 rcl7
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 PnnciDle C Pressure Vacuum Breaker
D-" Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer ff- S
Model Number 7 7 �- A ,:�s G 'Its 14
Serial Number .' a o i /US'
Size
Located At V x') / -f d fi -2) t
The above is certified to be true. ,C
Firm Name
PY O /
Certified Tester
Firm Address 5~ , Cert. Tester No. 9 P6 o l z / 1 % Date Z
Gauge # S'
Date last accuracy tested / z -1 `7 - / Z
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 ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
2 " ("
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true. ,C
Firm Name
PY O /
Certified Tester
Firm Address 5~ , Cert. Tester No. 9 P6 o l z / 1 % Date Z
Gauge # S'
Date last accuracy tested / z -1 `7 - / Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy