2013_1212CHECK ONE:
IRRIGATION
DOMESTIC V
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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 1A A Tr S
Model Number C/' o0ini 2, 0 1
Serial Number 002,13q
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
01 Atmosphere Vacuum Breaker
Size P/4"
Located At /0,) Gl1 9LS'i __ S I DtCelAlK
OAl De4rod
The above is certified to be true.
Firm Name 1gT[A -jP, - �&EV/CE-c-
Firm Address 1,V311 G✓ECcw /2D.
/- Al2M6/t j L q4-x -f , 7x-,
Gauge # V11 '] (
Date last accuracy tested
Certified Tester jet ggm v
Cert. Tester No. !� P OW I / 21 Date 12 -12-1-3
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 X
Opened at
Opened at
nsid
SASS
Tight ❑
RP- /• . Dsid
Leaked ❑
osid
nsid
2' /z'' z
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name 1gT[A -jP, - �&EV/CE-c-
Firm Address 1,V311 G✓ECcw /2D.
/- Al2M6/t j L q4-x -f , 7x-,
Gauge # V11 '] (
Date last accuracy tested
Certified Tester jet ggm v
Cert. Tester No. !� P OW I / 21 Date 12 -12-1-3
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy