2013_0823 (3)CHECK ONE: /
IRRIGATION , DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has beep 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 V' L07
Model Number
Serial Number Alin 5-io
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located AtT�
1
The above is certified to be true.
Firm Name k ! ! ; r Certified Tester 71�4 W� w, _
FirmAddr=45A Cent. Tester No. 1 74(1 Date t
f� -We -1� —76a4itt
Gauge # 0( o-) 1:3eiy'
Date last accuracy tested 14
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
Closed Tight
Opened at
Opened at
osid
�0'5 �
Tight-
RP- of f Dsid
Leaked ❑
Leaked ❑
2.
asid
usid
Did not Open C3
Leaked
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__asid
Repair
Tight ❑
psid
asid
RP sid
The above is certified to be true.
Firm Name k ! ! ; r Certified Tester 71�4 W� w, _
FirmAddr=45A Cent. Tester No. 1 74(1 Date t
f� -We -1� —76a4itt
Gauge # 0( o-) 1:3eiy'
Date last accuracy tested 14
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy