2013_0201 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: -� D Ze S /1/A I ST it 13 9, f--/, n
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer wa ff S Size
Model Number U ° ! t4l / �s G
Scrial Number 4' `f '7 S 6
Located At Yap %f t - . t+rc: n c
The above is ccrtified to be true.0
We
Firm Name Certified Tester.
Firm Address ' +� ?�,� , r, e- ' Cert. Tester No. 73 Date Z'
Gauge # 5 Sv S,
Date last accuracy tested /2- - / `T '-/ 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 ❑
osid
oSid
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 ccrtified to be true.0
We
Firm Name Certified Tester.
Firm Address ' +� ?�,� , r, e- ' Cert. Tester No. 73 Date Z'
Gauge # 5 Sv S,
Date last accuracy tested /2- - / `T '-/ Z-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy