2013_0716 (2)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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C, Atmosphere Vacuum Breaker
Manufacturer 41'1 iii /1/. l I? -� Size
Model Number 7 �� �L Located At
Scrial Number 3 ?� %
The above is certified to be true.
Firm Name .O &1 YD C0121172 Certified Tester 3 6?
Firm Address '`, d - V" A L: Cat. Tester No. d PzZ nl�/ ! "� Date -) /-
�G�vgC/
Gauge # C 'SAD 20 ors a
Date last accuracy tested
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 C
Opened at
Opened at
nSid
Tight �J�S ❑
Leaked C
nsid
nSid
RP -_psid
Leaked C
Did not Open D
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nSid
Repair
Tight 0
nsid
nSid
RP sid
The above is certified to be true.
Firm Name .O &1 YD C0121172 Certified Tester 3 6?
Firm Address '`, d - V" A L: Cat. Tester No. d PzZ nl�/ ! "� Date -) /-
�G�vgC/
Gauge # C 'SAD 20 ors a
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy