2013_0122 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE x
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME 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.
M Reduced Pressure Principle
Ir_ Double Check Valve
Manufacturer
Model Number
Serial Number I 'S i 5
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
,\
Size i
Located At ci k �D e
r
The above is certified to be true.
Firm Nam& �' c
�2
Firm Address,2 4 75-0,00
Gauge # 3-1d 3,5--3
Date last accuracy tested /- J0?- / 3
JUM BREAKER
Check Valve
nSid
Leaked ❑
nsid
t
Ft e RE X11 / n't �
Cent. Tester No,6 no l Q-7 73 Date ' a 5-" 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight &
Opened at
Opened at
Ti ,t
Leaked ❑
osid
nSid
v `t
Leaked ❑
�`-
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Tight 13
psid
nSid
IP7air
RP sid
The above is certified to be true.
Firm Nam& �' c
�2
Firm Address,2 4 75-0,00
Gauge # 3-1d 3,5--3
Date last accuracy tested /- J0?- / 3
JUM BREAKER
Check Valve
nSid
Leaked ❑
nsid
t
Ft e RE X11 / n't �
Cent. Tester No,6 no l Q-7 73 Date ' a 5-" 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy