2013_0308CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The backnow 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
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
t� �
Model Number
7 7 ��
Serial Number
G C/
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At V
The above is certified to be true.
Firm Name',` 1/0`
Firm Address G , l 7 t L r, y
Gauge # _L,) G U ` 1 I :7 4� C'
Date last accuracy tested Y -/ -2 "-/
Certified Tester? / /,G�� `
Cent. Taster No. i %� '� 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 y
Tight )!k
Closed Tig ; l9
Leaked ' ❑
Opened at
__.psid
Opened at
_osid
usid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-- sid
Repair
Tight ❑
nsid
______-_osid
RP sid
The above is certified to be true.
Firm Name',` 1/0`
Firm Address G , l 7 t L r, y
Gauge # _L,) G U ` 1 I :7 4� C'
Date last accuracy tested Y -/ -2 "-/
Certified Tester? / /,G�� `
Cent. Taster No. i %� '� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy