2013_0619 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /V-
JK CAF
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
W
Manufacturer rLr- w S
Model Number 95 U XL.T
Serial Number 25 :�
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
I
Size i /-.
Located At A l U- W. eo ,
The above is certified to be true.
-N Ile Firm Name. ` /1,' Certified Tester U�/UiU /fL
Firm Address IJ'r.5 TAB �r l�� �X %y& Cat Tester No. �P� ^` � � , Date
Gauge #
Date last accuracy tested ' -1 /—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
��
DC- Closed
Tight ❑
RP- pSid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
oSid
Opened at
nSid
Did not Open ❑
nsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
-N Ile Firm Name. ` /1,' Certified Tester U�/UiU /fL
Firm Address IJ'r.5 TAB �r l�� �X %y& Cat Tester No. �P� ^` � � , Date
Gauge #
Date last accuracy tested ' -1 /—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy