2013_0716 (8)CHECK 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
n Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer .1i //l //7S Size .11-112
Model Number 9 5 0 ,,YL. Located At Y se r Y./)aey7 7
Serial Number 36 9
The above is certified to be true.
Firm Name Me' (Y& C-
Firm Address
21�1 d 9
Gauge # Goya 0,.c
Date last accuracy tested
411j2hA
Certified Tester f e r r y fCkCQ,,4�
Cart. Tester �lli L 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?,y
RP -_ _psid
Leaked Ll ❑
/
Dsid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Me' (Y& C-
Firm Address
21�1 d 9
Gauge # Goya 0,.c
Date last accuracy tested
411j2hA
Certified Tester f e r r y fCkCQ,,4�
Cart. Tester �lli L Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy