2013_0122 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE r
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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer L'vve-5
Model Number_C (-
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
tr
Size l
Located At r �.
9 i
Gauge # e 37 2,3 6-3
Date last accuracy tested % - ? .12 ./ 3
JUM BREAKER
Check Valve
nsid
Leaked ❑
__-_p sid
Cert. Tester No.�JC7bl y 7 %3 Date q --� 5' /.3
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 's
RP's,,^ Dsid
Leaked ❑
Leaked ❑
o C
osid
nsid
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
nsid
nsid
RP sid
9 i
Gauge # e 37 2,3 6-3
Date last accuracy tested % - ? .12 ./ 3
JUM BREAKER
Check Valve
nsid
Leaked ❑
__-_p sid
Cert. Tester No.�JC7bl y 7 %3 Date q --� 5' /.3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy