2013_1003CHECK ONE:
IRRIGATION
DOMESTIC X, FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
n
LOCATION OF SERVICE: U/ s• � , 41: y /;�
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
St
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number / y 7 `i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
"f
Size
Located At
r L
The above is certified to be true.
Firm Name / ;c �ic r� /- / x zf
Firm Address PG' •i� ,r 7 -� 7
Gauge # lJ (p ' j 7 Y C
Date last accuracy tested y -r -/,,7
Certified Tester / I 'tt 5
Cert. Testa No. 1} "ei L' Ov 7y' Date / 6 t 1�73
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 2 '-"
Closed Tight fal
Leaked / 4 ❑
Opened at
nsid
Opened at
oSid
osid
RP -_ psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs and
7l
r
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name / ;c �ic r� /- / x zf
Firm Address PG' •i� ,r 7 -� 7
Gauge # lJ (p ' j 7 Y C
Date last accuracy tested y -r -/,,7
Certified Tester / I 'tt 5
Cert. Testa No. 1} "ei L' Ov 7y' Date / 6 t 1�73
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy