2013_0716 (13)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: "r /,CY -r'U?-
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 ���� /,J 1'l 5 Size `�� f
.2
Model Number � S D X L Located At Ise Y Yo0147 11141--
Serial Number
The above is certified to be true.
Firm Name lVe fro Cvn,, ri,
Firm Address 1006 /-Ws e v. "A u
1'x 76 0 s
Gauge # D'S 0 Ve f54
Date last accuracy tested
Certified Tester J d er4 52 1116 o k
Cert. Tester No. I PiIA"%6 ; -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
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name lVe fro Cvn,, ri,
Firm Address 1006 /-Ws e v. "A u
1'x 76 0 s
Gauge # D'S 0 Ve f54
Date last accuracy tested
Certified Tester J d er4 52 1116 o k
Cert. Tester No. I PiIA"%6 ; -Date-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy