2013_0411 (16)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: (Y�cari�u K�v17
cq "Cx
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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer \ ��
Model Number C 5
Serial Number 2"�Q
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size I `la , `
Located At Sep-
The above is certified to be true.
Firm Name �' Certified Tester
Firm Address �' r Cent. Tester No. 614) () (f 91 % Date 4? /11 f 3
Gauge #
Date last accuracy tested 7//& / Q-
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 ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name �' Certified Tester
Firm Address �' r Cent. Tester No. 614) () (f 91 % Date 4? /11 f 3
Gauge #
Date last accuracy tested 7//& / Q-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy