2013_0614 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:,-/
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
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
ce
Serial Number Gi �— l '3 t j
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At S f c IZI o' / C ` o! ire �r
The above is certified to be true.
Firm Name / �c l / �: j o l f Certified Tester`' ✓� Lax l �o o� S
l/
Firm Address L', l jam`. '� r yxl TCert. Tester No. Date
Gauge #'C
f
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 `' '-/
Closed Tight �
Leaked /� , ❑
Opened at
nsid
Opened at
osid
osid
RP- ._._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name / �c l / �: j o l f Certified Tester`' ✓� Lax l �o o� S
l/
Firm Address L', l jam`. '� r yxl TCert. Tester No. Date
Gauge #'C
f
Date last accuracy tested �;-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy