2013_0912 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: � 2% 5 /cCZ,,'
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
Double Check Valve
Manufacturer
Model Number d C
Serial Number d 0 Y 3 6 q
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
ri Atmosphere Vacuum Breaker
r
size
Located At �� I m
The above is certified to be true.
n
Firm Name / 7c lc- /-L11-
Firm Address i &' �`' Y 1 7 t ✓ r'��. Tv
Gauge #
Date last accuracy tested -'/ -.> 1-�
Certified Tester fl) I � `
Cert. Tester No. 117XL,C'07c-2 Date `1 ' /`
?
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 3 -G>
Closed Tight )t
Leaked -3-0 C
Opened at
nsid
Opened at
nsid
nsid
RP -_psid
Leaked a
Did not Open O
Leaked C
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight C
nsid
nsid
RP sid
The above is certified to be true.
n
Firm Name / 7c lc- /-L11-
Firm Address i &' �`' Y 1 7 t ✓ r'��. Tv
Gauge #
Date last accuracy tested -'/ -.> 1-�
Certified Tester fl) I � `
Cert. Tester No. 117XL,C'07c-2 Date `1 ' /`
?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy