2013_0204 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
Z ► `7 t4144µ.
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
tla Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer A%,4.sU Size �f�l
Model Number FD C-- Located At �/ u
Serial Number �7 %
The above is certified to be true.
Firm Name
Firm Address
Gauge # v 7
Date last accuracy tested
Certified Tester
Cert. Tester No. t? err° i y r' Date
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 Va
Closed Tight 0
Leaked ❑
Opened at
osid
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
Firm Address
Gauge # v 7
Date last accuracy tested
Certified Tester
Cert. Tester No. t? err° i y r' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy