2013_0613 (6)CHECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW 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 been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
G 7
1'5C'f"?
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name /� t �(r Certified Tester / i z "' 11 ,19 Jf -
Firm Address 0 I ;C x % l7 L v.� %��� , Cert. Tester Nofi1110e-y,>-' d c . -� Date
Gauge # 6 & &-/ / 7 `l' Z'
Date last accuracy tested `l 5. 1,3
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
osid
Tight ❑
Leaked ❑
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Ater
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name /� t �(r Certified Tester / i z "' 11 ,19 Jf -
Firm Address 0 I ;C x % l7 L v.� %��� , Cert. Tester Nofi1110e-y,>-' d c . -� Date
Gauge # 6 & &-/ / 7 `l' Z'
Date last accuracy tested `l 5. 1,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy