2013_0614 (5)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 bacldlow 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 °' A/
Model Number 7
Serial Number �r ,
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Sue
Located At
The above is certified to be true.
Firm Name 6 <� %" �' n Certified Tester
Firm Address 1' l l lC/�?` Cwt. Tester No. �� �c?ef.t -L Date
Gauge # y t 6' /j / '�' "'
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 :- °
RP- ._,_psid
Leaked p
Closed Tight
Leaked ❑
31 12..
Opened at
psid
Opened at
nsid
Did not Open o
flsid
Leaked C
Repairs
and
Materials
Used
Test After
DC- Closed
Closed not o
Opened at
Opened at
_ nsid
Repair
Tight o
flsid
nsid
RP sid
The above is certified to be true.
Firm Name 6 <� %" �' n Certified Tester
Firm Address 1' l l lC/�?` Cwt. Tester No. �� �c?ef.t -L Date
Gauge # y t 6' /j / '�' "'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy