2013_0411 (22)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACI{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer \r-t- Size 1 !„t
Model Number
Serial Number
I
Ri- [.tr►2
Located At I,
The above is certified to be true.
Firm Name
Firm Address
v
Gauge # -7 qO
Date last accuracy tested
Certified Testa , - V , . 1 r" ( ! , + 1 q N
Cert. Testa No.' g 1 1 q l') Date )/11//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 ❑
Leaked ❑
nsid
osid
RP - _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address
v
Gauge # -7 qO
Date last accuracy tested
Certified Testa , - V , . 1 r" ( ! , + 1 q N
Cert. Testa No.' g 1 1 q l') Date )/11//3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy