2013_0220 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 162 1 t LLM • f oDA�LC 'r�C X501 �
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 C Pressure Vacuum Breaker
VDouble Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturers Size 31 g ,,
Model Number DO TI I Located At 1I E V0,111- as hi &
Serial Number
The above is certified to be true.
)y I I rf
(:) 1i
Date last accuracy tested /?- /a
Certified Tester
Cert. Tester No. q10 7i 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
Closed Tight b(
Opened at
Opened at
vsid
Tight
RP -vsid
Leaked ❑
Leaked ❑
�'
psid
vsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
vsid
_ osid
RP sid
The above is certified to be true.
)y I I rf
(:) 1i
Date last accuracy tested /?- /a
Certified Tester
Cert. Tester No. q10 7i Date ?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy