2013_0716 (3)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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number 15 6 k L-
Serial Number 3 9 9 &b 3
Size
Located At )0Y-2/�%4
The above is certified to be true.
Firm Name 'NP' rr % Cc) ^ o4,
Firm Add= f44141 7 6�rAvcyl w
TK ;7GU55
Gauge #
Date last accuracy tested
Certified Tester
Cert Testa No.51°O,nG ( Oi Date ' /l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tisht�� (f ❑
Leaked ❑
vsid
oSid
RP- ,_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name 'NP' rr % Cc) ^ o4,
Firm Add= f44141 7 6�rAvcyl w
TK ;7GU55
Gauge #
Date last accuracy tested
Certified Tester
Cert Testa No.51°O,nG ( Oi Date ' /l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy