2013_0823 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC)GLOW 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 hA been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
Double Check Valve
Manufacturer �Jli�
Model Number C92-1 Wks
Serial Number!
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size 1 �-
Located At �i I
The above is certified to be true.
Firm Name �y4 Certified Tester MIr
Firm Address NSA 41 0%* a .*a"o `� Cent. Tester No. P004,1144 i`d4 Date $
9- W-' ,F -74244
Gauge #0`�4"]��
Date last accuracy tested p
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
vsid
Tight
RP- a . 0 psid
Leaked 0
Leaked o
�• L
vsid
vsid
Did not Open o
Leaked
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Repair
Tight a
vsid
vsid
RP sid
The above is certified to be true.
Firm Name �y4 Certified Tester MIr
Firm Address NSA 41 0%* a .*a"o `� Cent. Tester No. P004,1144 i`d4 Date $
9- W-' ,F -74244
Gauge #0`�4"]��
Date last accuracy tested p
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy