2013_0311 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
L. L4 V 110 A--r` L
LOCATION OF SERVICE: 3 G R (b I `J`� 6
— r�
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
resulations and is certified to be operating within acceptable parameters.
Reduced Pressure Principle
Double Check Valve
Manufacturer
k) (I
PRESSURE VACUUM BREAKER
Model Number
11 d 1
Serial Number
�3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size cS G } si ��
Located At %� D�! 0"4
The above is certified to be true.
Firm Name
Firm Address 3 0� 3 - W
Gauge # )
Certified Tester JJ4 JIACI
Cent. Tester No. (b Date
Date last accuracy tested
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 ❑
RP- �,psid
Leaked ❑
Closed Tight 0
Leaked ❑
8-
Opened at
, psid
Opened at
oSid
Did not Open ❑
osid
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 3 0� 3 - W
Gauge # )
Certified Tester JJ4 JIACI
Cent. Tester No. (b Date
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy