2013_0716 (12)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Y15 05ZW"V&-rC ^%apt sc.,,br_ 2r0/ �
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 C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At Y /Ocy"` 7
The above is certified to be true.
.. kk 1/ li
Firm Address 0,,4,6,a6 7 Grp
* 7609
Gauge # 6 g!) V0,S S 67
Date last accuracy tested e /D .1 2
Certified Tester Se r r u Scka A
Cat Tester No. ?'fte 8'G G 4 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
Ininal Test
DC- Closed
Closed Tight
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
DSid
oSid
RP- __esid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
esid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
.. kk 1/ li
Firm Address 0,,4,6,a6 7 Grp
* 7609
Gauge # 6 g!) V0,S S 67
Date last accuracy tested e /D .1 2
Certified Tester Se r r u Scka A
Cat Tester No. ?'fte 8'G G 4 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy