2013_0715 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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 has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer 1 w ,1 )A 1 -r S
Model Number �' °'
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name AJ e , �•
If 17 Cowl '
Firm Address _�
N �,oTKSU
Gauge #
Date last accuracy tested q 7 1
Certified Tester r'
i.,,,.,ft
Cert. Tester No. 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
Tight ❑
RP- pSid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
�<-
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
oSid
nsid
RP sid
The above is certified to be true.
Firm Name AJ e , �•
If 17 Cowl '
Firm Address _�
N �,oTKSU
Gauge #
Date last accuracy tested q 7 1
Certified Tester r'
i.,,,.,ft
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy