2013_0912 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE \-,
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: S i"`a 0 Y "-I l
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.
C Reduced Pressure Principle
Y.l Double Check Valve
Manufacturer e tc S ,? y
Model Number �~ C�l &-
Serial Number
'7'o 3 f -;
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size y y
Located At IP, 0,, l/ W f 5/(11
The above is certified to be true.
Firm Name A )1e a,w Certified Tester /J/'/
Firm Address P0.5, X -7 r 7 1,11IZ x-71 Cent. TesterNo.
Gauge # 06 C' y / 7 � ir'
Date last accuracy tested
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 /'C
Opened at
Opened at
oSid
Tight /, �'
Leaked/. S' ❑
vSid
oSid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
nsid
vSid
RP sid
The above is certified to be true.
Firm Name A )1e a,w Certified Tester /J/'/
Firm Address P0.5, X -7 r 7 1,11IZ x-71 Cent. TesterNo.
Gauge # 06 C' y / 7 � ir'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy