2013_0716CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: r_� "'Ve- Ye`ir�
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve a Atmosphere Vacuum Breaker
/ ,
Manufacturer 14 /i //� l � Size I /IA
Model Number 9 7 40 x<--'- Located At Y,/ SC°��'�'4/�1�k L L
Serial Number
The above is certified to be true.
Firm Name.-I% f rt, C u In
Firm Address A9 13J A&? Knri, Dcttj,
, k 7lr � y y
Gauge # QYSo I/Q 15 O
Date last accuracy tested /0 6
Certified Tester -5"C �o y,
Cert. Testa No. - Date �f0
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight , '
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
RP -_psid
Leaked ❑
�'
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-----.psi d
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name.-I% f rt, C u In
Firm Address A9 13J A&? Knri, Dcttj,
, k 7lr � y y
Gauge # QYSo I/Q 15 O
Date last accuracy tested /0 6
Certified Tester -5"C �o y,
Cert. Testa No. - Date �f0
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy