2013_0411 (20)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
r
LOCATION OF SERVICE:
x
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
Double Check Valve
Manufacturer ��-hr n
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Model Number >� 'f Located At
Serial Number r)1 1 Z
� ` 4-1
The above is certified to be true.
�
Firm Name ( Certified Tester
Firm Address nC� �' Cert. Tester No. Date
X �.
Gauge # ' -' 17S 9
Date last accuracy tested 7 A 6 t
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
DSid
Tight ❑
RP -_Dsid
Leaked ❑
Leaked O
DSid
nSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nsid
Repair
Tight ❑
Dsid
nSid
RP sid
The above is certified to be true.
�
Firm Name ( Certified Tester
Firm Address nC� �' Cert. Tester No. Date
X �.
Gauge # ' -' 17S 9
Date last accuracy tested 7 A 6 t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy