2013_0411 (18)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
cc,
The baclflow 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 r . r n
Model Number %u�
Serial Number 1;6-75 -? t `
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size r Vd
Located At
The above is certified to be true.
Firm Name Certified Tester M I C h ��
Firm Address � No { Ccrt Tester No. ` fx101 , Date , �I ! !
Gauge # 33 ! 7 t
Date last accuracy tested
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 ❑
oSid
oSid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name Certified Tester M I C h ��
Firm Address � No { Ccrt Tester No. ` fx101 , Date , �I ! !
Gauge # 33 ! 7 t
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy