2013_0204 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: j
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
C Double Check Valve
Manufacturer
Model Number �vS
Serial Number ' r- " '- Cb
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
G Atmosphere Vacuum Breaker
Size ,
Located At
The above is certified to be true.
Firm Name Q C4, -- J'z r Certified Tester
Firm Address r;" ,V 2 - , ,, LZ Cent Tester No. Date
Gauge #
Date last accuracy tested 7- 3 f- ? 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 i a"
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
osid
RP -_psid
Leaked ❑
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name Q C4, -- J'z r Certified Tester
Firm Address r;" ,V 2 - , ,, LZ Cent Tester No. Date
Gauge #
Date last accuracy tested 7- 3 f- ? L-
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy