2013_0125 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPEL L
PWS I.D. #
LOCATION OF SERVICE:
I
-750 1 �
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer A i iC.i Yl° Size
r�
Model Number 6D - Located At Je- Pe r
Serial Number , ayLA LT
The above is certified to be true.
Firm Name � � h i, , - t- i t e-
Firm Address]
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa 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 ❑
Closed Tight ❑
Leaked Cl
Opened at
vsid
Opened at
nsid
nsid
RP- _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP !id
The above is certified to be true.
Firm Name � � h i, , - t- i t e-
Firm Address]
Gauge #
Date last accuracy tested
Certified Tester
Cert. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy