2013_0614 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
``it"" Double Check Valve
Manufacturer
Model Number 7
Serial Number / 6
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
z!
Size
Located At
0
y4 6, 0--
The above is certified to be true.
Firm Name ). da' �, .
Firm Address � '' /i L'104
Gauge # z' Z, Z,' 'I) / 1' t'
Date last accuracy tested '
Certified Tester
Cat Tests No. l.�I<',;
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM B R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight y 1;?- A
Closed Tight X
Leaked )- ,2-- ❑
Opened at
oSid
Opened at
oSid
osid
RP- ____psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Sid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name ). da' �, .
Firm Address � '' /i L'104
Gauge # z' Z, Z,' 'I) / 1' t'
Date last accuracy tested '
Certified Tester
Cat Tests No. l.�I<',;
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy