2013_0204CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE
�/17
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.
e Reduced Pressure Principle
❑ Double Check Valve
Manufacturer_
Model Number ' G
Serial Number 4 lIX
TYPE OF ASSEMBLY,,,
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size 511/
Located At
5. W t-, G
The above is certified to be true.
Firm Name
Certified Tester` _
Firm Address `' .; ./ -74 -7 I Z/ :,i Cert. Testa No. n 7 Date
Gauge #
Date last accuracy tested 7- 3 / - ), -L-
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 ❑
Closed Tight Z
Leaked ❑
Opened at
psid
Opened at
oSid
pSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
pSid
psid
RP sid
The above is certified to be true.
Firm Name
Certified Tester` _
Firm Address `' .; ./ -74 -7 I Z/ :,i Cert. Testa No. n 7 Date
Gauge #
Date last accuracy tested 7- 3 / - ), -L-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy