2013_0628 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKnOW 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.
C / Reduced Pressure Principle
Double Check Valve
Manufacturer \Q; `
Model Number �� }
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
�N
era
Located At
The above is certified to be true.
I JI VU
Firm Name Certified Tester Al 14N,
Firm Address Y,�' Cert. Tester No. 1 Date
Gauge # viAt Q ' V j1tq
Date last accuracy tested tj
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
'ef Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Tight • 0 ❑
Closed Tight
Leaked ❑
Opened at
osid
Opened at
vsid
vsid
�hjj
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
I JI VU
Firm Name Certified Tester Al 14N,
Firm Address Y,�' Cert. Tester No. 1 Date
Gauge # viAt Q ' V j1tq
Date last accuracy tested tj
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy