2013_0415CHECK ONE: /
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: k
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 Reduced Pressure Principle
2� Double Check Valve
Manufacturer
Model Numbers
Serial Number / )3,T
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
jUM BREAKER
Check Valve
nsid
Leaked ❑
....... sid
The above is certified to be true.
Firm Nam ir��f -u�,.• c Certified Tester It 1
Firm Adme442 &k / /.Q �M Llki .T Cert. Tester No. `7 / Date
Gauge #Clo0T/ tai
Date last accuracy tested / Z -/L —
/Z-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
Tight /• &
Leaked ❑
psid
nsid
RP -_ psid
Leaked ❑
Did not Open ❑
Repairs
and
Materials
Used
Test Altar
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight Cl
nsid
nsid
RP sia
jUM BREAKER
Check Valve
nsid
Leaked ❑
....... sid
The above is certified to be true.
Firm Nam ir��f -u�,.• c Certified Tester It 1
Firm Adme442 &k / /.Q �M Llki .T Cert. Tester No. `7 / Date
Gauge #Clo0T/ tai
Date last accuracy tested / Z -/L —
/Z-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy