2013_0104 (18)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: k 14 ' 7
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.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer L-J - fi
Model Number QUci Q i
Serial Number A cl S-3-7 i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 1/19'' Located At At "Ve-
The above is certified to be true.
Firm Name Al he d -�e. Pr, E F e
Firm Address Altuat 03(y
c,Ic-- ,t(,TX 775"11
Gauge # 0911�ai�4t.
Date Last accuracy tested
Certified Tester r e s / ). - /W . I
Cert. Tester No. 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 ❑
RP- Llusid
Leaked ❑
Closed Tight 0
Leaked ❑
Opened at
�-� . ck psid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name Al he d -�e. Pr, E F e
Firm Address Altuat 03(y
c,Ic-- ,t(,TX 775"11
Gauge # 0911�ai�4t.
Date Last accuracy tested
Certified Tester r e s / ). - /W . I
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy