2013_0628 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE '1Z
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
,2'0 Double Check Valve
Manufacturer L )
Model Number Ot) -7 Al
Scrial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
1! 'I
Size 7
Located At SiW U ek %-^. 1
The above is certified to be trues.
Firm Name -4C�V -t E4::j:;�i�
Certified Tester A L 61 ! -5
Firm Address �2J, � ` 12 Cert Taster No. 7 Date -
Gauge # a010 %-,j U
Date last accuracy tested -�I.-5 -13
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
Closed Tight X
Opened at
Opened at
nsid
Tight je
RP- -11 sid
Leaked ❑
. . o
psid
nsid
Leaked ❑
`li
Did not Open ❑
Leaked ❑
Reps
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 trues.
Firm Name -4C�V -t E4::j:;�i�
Certified Tester A L 61 ! -5
Firm Address �2J, � ` 12 Cert Taster No. 7 Date -
Gauge # a010 %-,j U
Date last accuracy tested -�I.-5 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy