2013_0716 (18)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICEa' dr%4i veYCl,gZ6 %3fs'AL a�s� fir. O/ 9
The backflow 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
C Double Check Valve n Atmosphere Vacuum Breaker
Manufacturer 1 /. ,,rl5 Size 2
Model Number �a� Located At {`_1 X/�D�1 /✓,
Scrial Number
The above is certified to be true.
Firm Name
Firm Addmssf a /,96,7
Gauge #
Date last accuracy tested /040 //"I-
Certified Testerta Y Y cl �G1J 60 f�
Cert. Tester No.l3P &u0£fG�a— Date 2116111 3
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 ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Addmssf a /,96,7
Gauge #
Date last accuracy tested /040 //"I-
Certified Testerta Y Y cl �G1J 60 f�
Cert. Tester No.l3P &u0£fG�a— Date 2116111 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy