2013_0314 (2)CHECK ONE:
IRRIGATION DOMESTIC_ s FIRELINE Z__
BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: -9 () e' ' /. e �J
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.
❑C
Reduced Pressure Principle
Double Check Valve
Manufacturer
tI, / i �
Model Number
On G j14 ?-
Serial Number
1 3 5t
1st Check
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name 4c / / e `- " / n Certified Tester
Firm Address G'. /3L Gf 7 tb)AKv T Cent. Testa No. l.?1 000' � Date
Gauge # e;&- & 41) 7
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
Closed Tight $
Opened at
Opened at
vsid
Tight `QI
Leaked JP-; ❑
nsid
vsid
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
_ _ nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name 4c / / e `- " / n Certified Tester
Firm Address G'. /3L Gf 7 tb)AKv T Cent. Testa No. l.?1 000' � Date
Gauge # e;&- & 41) 7
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy