2013_0716 (4)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 bac0ow 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
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer l� �i /K r �S Size
Model Number Located At
Serial Number �1 S121 el
The above is certified to be true.
Firm Name ,We r Yv rl) M I—n,
Firm Address f U6 /2 &7 lxyet ao'✓, i� o
�x 2&U9q
Gauge # 060416)'13-4-6
Date last accuracy tested /
Certified Tester e- r Y �► �U
Cert. Tester No..V-6=z1,69 Date
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 �'/ 3 ZI
Leaked ❑
Dsid
vsid
RP -_psid
Leaked ❑
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
psid
vsid
RP sid
The above is certified to be true.
Firm Name ,We r Yv rl) M I—n,
Firm Address f U6 /2 &7 lxyet ao'✓, i� o
�x 2&U9q
Gauge # 060416)'13-4-6
Date last accuracy tested /
Certified Tester e- r Y �► �U
Cert. Tester No..V-6=z1,69 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy