2013_0905 (7)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 4 � 4 )-'e 6,2o iii o4,4dlle %
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 C S
Model Number'G
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
l.,
Located At )"/,5- C r g g
The above is certified to be true.
Firm Name
Firm Address }� -
Gauge #
Date last accuracy tested to 0
Certified Tester j , Y -, 5 �C `P "6 ,
y
Cert. Tester No. 6M'C 8f 1� 9 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
RP -_psid
Closed Tight
Leaked ❑
Opened at
osid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address }� -
Gauge #
Date last accuracy tested to 0
Certified Tester j , Y -, 5 �C `P "6 ,
y
Cert. Tester No. 6M'C 8f 1� 9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy