2013_0716 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICEA#A), C,4 ase1J1 -6 ,'y e%tASC
The back-11ow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturer Size
Model Number � YL �7- Located At ' A� Y401'T
Serial Number 35-7
The above is certified to be true.
Firm Name 40 I Yu r..nm
FirmAddressAK-4 /Z Gr -aQQyA
yX 7G09
Gauge # O$'0VD ,1S O
Date last accuracy tested /U 1
Certified Tester r yal SCAcc, A
Cat. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
oSid
oSid
RP- _pSid
s4,
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name 40 I Yu r..nm
FirmAddressAK-4 /Z Gr -aQQyA
yX 7G09
Gauge # O$'0VD ,1S O
Date last accuracy tested /U 1
Certified Tester r yal SCAcc, A
Cat. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy