2013_0522 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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 C Pressure Vacuum Breaker
C Double Check Valve r, Atmosphere Vacuum Breaker
Manufacturer
— �/���� Size }�
Model Number
�0� al 4" Located At a, al - c ar i
r�
Serial Number e 3
The above is certified to be true.
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
nsid
Check Valve
nsid
Did not Open ❑ I Leaked ❑
Opened at I nsid
nsid
Firm Name ya I(-), r Certified Tester i
Firm Address � t � 1 5 � PA rA r �} � 1 i Cem Tester No. 'T' P 1 Z �G1 3 Date 13
Gauge #y
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Tight
RP- • i psid"
Leaked ❑
a ':5 -sid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Repair
Tight ❑
nsid
RP sid
The above is certified to be true.
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
nsid
Check Valve
nsid
Did not Open ❑ I Leaked ❑
Opened at I nsid
nsid
Firm Name ya I(-), r Certified Tester i
Firm Address � t � 1 5 � PA rA r �} � 1 i Cem Tester No. 'T' P 1 Z �G1 3 Date 13
Gauge #y
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy