2013_0411 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFI.OW 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.
C Reduced Pressure Principle
C Double Check Valve
Manufacturer t- E B C, b
Model Number 965,
Serial Number Rk3 R 6 I
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name -TaIA I r` ► R r Certified Tester e
Firm Address ? 9 r ?q CASK � iJ Cent. Tester No. �' � � Date
Gauge # ? 7 �1
Date last accuracy tested 7/) (9/ I
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
osid
Check Valve
osid
Did not Open ❑ 1 Leaked ❑
Opened at I osid
osid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check:
2nd Check:
Relief Valve
Initial Test
d
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
RP -_psid
Leaked ❑
Repairs
and
Materials
�F �L
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Repair
Tight ❑
osid
RP sid
The above is certified to be true.
Firm Name -TaIA I r` ► R r Certified Tester e
Firm Address ? 9 r ?q CASK � iJ Cent. Tester No. �' � � Date
Gauge # ? 7 �1
Date last accuracy tested 7/) (9/ I
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
osid
Check Valve
osid
Did not Open ❑ 1 Leaked ❑
Opened at I osid
osid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy