2013_0204 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back low 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
Double Check Valve
Manufacturer t-'1
Model Number b C
Serial Number " fa
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size X
Located At
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
�,-�
Firm
Relief Valve
Air Inlet
Check Valve
Ist Check
2nd Check: Z
Initial Test
DC- Closed
Tight d
Closed Tight -d'
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP- _psid
Leaked ❑
Did not Open D
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm
Name
vr✓,�_
�,-�
Firm
Address
P0;90-1
Gauge # > 7 P!2 d �/ ,?w
Date last accuracy tested ' 7-31- ! a--
Certified Tester hPrrr74t ,
Cat Tester No. g r a 6 is 7 Date Z- y_ 2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy