2013_0607CHECK ONE:
IRRIGATION
DOMESTIC
FIFLELINE
BACI¢LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAW[E OF PWS: CITY OF COPPELL
PWS I.D. # _
LOCATION OF SERVICE :�
The backflow 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 a Pressure Vacmmm Breaker
m/ Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer of ( / k ° n S size
Model Number -350 Located At
Serial Number R,2- S 9 9 '13
The above is certified to be true.
Firm Name
C <C� 11 L , PVIJ�f Ch�:A--) Certified Tester --�
Cat Tester N ' ....L�-
Firm AddressLGi Date
Gauge # 0 CV J
Date last accuracy tested 7 4 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
PdSS
DC- Closed
Tim �'-� Q-
Closed Tight Er
Leaked ❑
Opened at
nsid
Opened at
�.vsid
—j)s id
I1- a'S-13
RP•_psid
Leaked
Leaked ❑
07.
not Open ❑
Lealxd o
Repairs
an
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
_nsid
_Fsid
RP
The above is certified to be true.
Firm Name
C <C� 11 L , PVIJ�f Ch�:A--) Certified Tester --�
Cat Tester N ' ....L�-
Firm AddressLGi Date
Gauge # 0 CV J
Date last accuracy tested 7 4 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy