2013_1205CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE /
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer " 17`s
Model Number Ore 2 &!
Serial Number 3
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name tiG Sf C.r�7 -,m7es Aer -
Firm Address 'n k- &✓ / rI
Gauge # 3.qf4
Date last accuracy tested 3-7-/3
� //ICS`
Certified rester L3/(7i�934 �/
Cert. Tester No. ae /�Z! Tv 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
Tight /•,? CK
RP -psid
_Leaked ❑
,Closed Tight
Leaked ❑
Opened at
osid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
osid
Opened at
osid
_nsid
RP sid
The above is certified to be true.
Firm Name tiG Sf C.r�7 -,m7es Aer -
Firm Address 'n k- &✓ / rI
Gauge # 3.qf4
Date last accuracy tested 3-7-/3
� //ICS`
Certified rester L3/(7i�934 �/
Cert. Tester No. ae /�Z! Tv Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy