2013_0912 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE 1Y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 6 2 / 5- 16 y
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cmified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
'5r Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer rl f f% Size �/ y
Model Number" Located At
Serial Number
The above is certified to be true.
Firm Names
Certified Tester / �/ -' L vi ��?% -''
Firm Address Y'e%' /,7c x 71� L '��x �- r� Cent. Tester No. ��'f'�'t %' ~' Date
Gauge #
Date last accuracy tested �/ - -5 - / r?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check:
Initial Test
DC- Closed
Tight /' P
Closed Tight it
Leaked 2.0 ❑
Opened at
vSid
Opened at
vSid
vsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_vsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Names
Certified Tester / �/ -' L vi ��?% -''
Firm Address Y'e%' /,7c x 71� L '��x �- r� Cent. Tester No. ��'f'�'t %' ~' Date
Gauge #
Date last accuracy tested �/ - -5 - / r?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy