2013_0729 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
0 tv, / A- �[
The bac0ow 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
Model Number p
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
x /
Size
Located At
The above is certified to be true.
Firm Name At�t-- -L 62--'
Firm Address Cv 3=�- 712
/.c%.--114, 7j'!L r
Gauge # y 7 09 0 ` R:R
Date last accuracy tested `-
Catiified Testa rent Cat Tester Tester No.FP,:*O� iS 7 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:
'ef Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
R.P-sid
Closed Tight
Leaked C3
Opened at
2.6 psid
Opened at
psid
psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psid
Repair
Tight ❑
psid
tlsid
RP psid
The above is certified to be true.
Firm Name At�t-- -L 62--'
Firm Address Cv 3=�- 712
/.c%.--114, 7j'!L r
Gauge # y 7 09 0 ` R:R
Date last accuracy tested `-
Catiified Testa rent Cat Tester Tester No.FP,:*O� iS 7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy