2013_0314CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE__X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:!`
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.
❑
Manufacturer
Model Number
Reduced Pressure Principle
Doubie Check Valve
l(", "d f /s
77Z-/
Serial Number / G' 7 /
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size
Located At ��✓ �' 1 �� /-/�c�
The above is certified to be true.
Firm Name
c �, v L, / / -e Certified Tester j , �{ ) C � l
Firm Address
/� / y 7 7 G` 'dr �'� Cert Tester No. ,Mt9te) `711 Date
Gauge #& C 0 t/ / 7 j 0
Date last accuracy tested 9 -/,,? / ->-
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 j. o
Tight V
Closed Tight
Leaked �' o
Opened at
oSid
Opened at
oSid
oSid
RP -_ _psid
Leaked ❑
Did not Open o
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nSid
Opened at
oSid
_ nsid
RP sid
The above is certified to be true.
Firm Name
c �, v L, / / -e Certified Tester j , �{ ) C � l
Firm Address
/� / y 7 7 G` 'dr �'� Cert Tester No. ,Mt9te) `711 Date
Gauge #& C 0 t/ / 7 j 0
Date last accuracy tested 9 -/,,? / ->-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy