2013_0528CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE
('-2 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
^_ Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer Size -A
Model Number Z Located At vau,(-r /N
Serial Number
11 , q3
The above is certified to be true.
Firm Name D55 Fi/cF oarli
1641CT Mn t rr I-
Firm Address oAuAS . T,, -7s 23
Gauge #
Date last accuracy tested 1-7-13
Certified Tester
Cent. Tester No. Date 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 ❑
RP-_2 1 2 psid
Leaked ❑
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
____-psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name D55 Fi/cF oarli
1641CT Mn t rr I-
Firm Address oAuAS . T,, -7s 23
Gauge #
Date last accuracy tested 1-7-13
Certified Tester
Cent. Tester No. Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy