2013_0104 (13)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:.
The bac0ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer L",� fl� Size ,f
Model Number 80UMLi Q Located At A-)U-Q.
Serial Number � 1 l 5 7C
The above is certified to be true.
Firm Name A1 /,L•j -,e N,
Firm Address
c, /(,,, (. 7 X -750`I i
Gauge # ocj&)aU
Date last accuracy tested
Certified Tester ]t} ,Af s Al
Cert. Tester No. PAV I �)5 7 S Date L o7C 3
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
sid
Tight ❑
Leaked ❑
osid
nsid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name A1 /,L•j -,e N,
Firm Address
c, /(,,, (. 7 X -750`I i
Gauge # ocj&)aU
Date last accuracy tested
Certified Tester ]t} ,Af s Al
Cert. Tester No. PAV I �)5 7 S Date L o7C 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy