2013_1010CIIECK ONE:
IRRIGATION_ 4
DOMESTIC
FIRELINE
BACICMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAh E 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.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ) "- (- ° Size
Model Number
gg�
Serial Number #7)
Located At
The above is certified to be true.
Firm Name /lei ��, -�-' Certified Tester ---� n
Firm Address � y Wl �IDW °��SAYi�1 uS' %�- Cat Tester No: ° Date
Gauge # LlQ„?oD7 k-5-41
Date last accuracy tested 01-1-13
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 ,V
Opened at
Opened at
psid
Tight ❑
Leaked ❑
nsid
nsid
i < < tl,
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test ABcr
DC- Closed
Closed Tight ❑
Opened at
Opened at
—___---psi d
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name /lei ��, -�-' Certified Tester ---� n
Firm Address � y Wl �IDW °��SAYi�1 uS' %�- Cat Tester No: ° Date
Gauge # LlQ„?oD7 k-5-41
Date last accuracy tested 01-1-13
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy