2013_0208CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
YDouble Check Valve ❑ Atmosphere Vacuum Breaker
r
Manufacturer p J Size
Model Number Located At l-V? 6 �,� "tL'.i,t -" �QA
OL
Serial Number i't
The above is certified to be true.
Firm Name Ste' 010-a-li�, 4 13At k �1��7
Firm Address 4 xR lx; i l a Ao h
Gauge # LO
Date last accuracy tested i - aq- 13
Certified Tester 6 .6 4 C
Cat Tester Noj a,, jJ— Date 9 Ay /1 3
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
PASS
PASS
DC- Closed
Tight E C(
RP -- r' psid
Closed Tight It
Leaked ED
9"a
Opened at
osid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
psid
_____—p sid
RP sid
The above is certified to be true.
Firm Name Ste' 010-a-li�, 4 13At k �1��7
Firm Address 4 xR lx; i l a Ao h
Gauge # LO
Date last accuracy tested i - aq- 13
Certified Tester 6 .6 4 C
Cat Tester Noj a,, jJ— Date 9 Ay /1 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy