2013_0517 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
11%.
LOCATION OF SERVICE: 1 /� i C%� %u L- . e f t
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
Serial Number
Reduced Pressure Principle
Double Check Valve
,". i-1
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
rv� r J�
The above is certified to be true.
Firm Name r4- L((bl,'Certified Tester
r_r D —7 Cert. Tester No. Date
Firm Address
Gauge #")-7 Z t/t L
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
Closed Tight ❑
Opened at
Opened at
osid
Tight-) I `�
Leaked ❑
Dsid
osid
R- . l/Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name r4- L((bl,'Certified Tester
r_r D —7 Cert. Tester No. Date
Firm Address
Gauge #")-7 Z t/t L
Date last accuracy tested �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy