2013_0308 (2)CHECK ONE:
IRRIGATION DOMESTIC F^ FIRELINE
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.
1.1
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
0 6 7
Scrial Number /6 J 2/V
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
r
Size
Located At'��2
The above is certified to be true.
Firm Name i� c �� �� /'>/� Certified Tests
Firm Address �'� u ,)( ;7 �. � L%/► y h Cent. Tester No. fj� �'` L'� Date-.: - 4�
Gauge # ()G 0 0 l ! 40
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
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight / • 6
Closed Tight )'
Leaked ? -c ❑
Opened at
nsid
Opened at
nsid
nsid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight E3
Opened at
nsid
Opened at
nsid
p sid
RP sid
The above is certified to be true.
Firm Name i� c �� �� /'>/� Certified Tests
Firm Address �'� u ,)( ;7 �. � L%/► y h Cent. Tester No. fj� �'` L'� Date-.: - 4�
Gauge # ()G 0 0 l ! 40
Date last accuracy tested '-/ -/,)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy