2013_0125 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
In
LOCATION OF SERVICE: I
The back-flow 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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer W G1 ' 1 `_" Size
Model Number Located At r
Serial Number
aC �
The above is certified to be true.
Firm Name t 'ti i r 6g),] ! . Certified Tester
Firm Address V, J— { �4 - Cent. Tester No. Date
.`l;_
Gauge #
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 ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
nsid
nsid
lz -_�2�sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name t 'ti i r 6g),] ! . Certified Tester
Firm Address V, J— { �4 - Cent. Tester No. Date
.`l;_
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy