2013_0614 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE '
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1/ % -5 k7�
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
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
&r) ��714-r/
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
G Atmosphere Vacuum Breaker
Size
Located At y ��
The above is certified to be true.
Firm Name / % } ' a / / l Certified Tester A,
Firm Addrrss a ' rt
Gauge #
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 �"
Tight 16
Closed Tight
Leaked l -
Opened at
sid
Opened at
nsid
nsid
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name / % } ' a / / l Certified Tester A,
Firm Addrrss a ' rt
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy