2013_0122 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE X
13ACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. Al
CITY OF COPPELL
LOCATION OF SERVICE:
C—
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
Double Check Valve Assembly
Model Number
Cs c c~,
Serial Number
.°
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
�.t
Size I
Located At
The above is certified to be true.
Firm Name � Certified Tester �n d a SaIV Ma
acs � , e Ct i�-L
Firm Address Casar/al)d 'T,e- -75-L 4v Cert. Tester No. &P06 t0T 73 Date C1,
Gauge #37 Z 3 53
Date last accuracy tested / • �2 Z • r_3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight A�,
Opened at
Opened at
osid
R-55
Tight 5
RP- ,2
Leaked ❑
Leaked ❑
oSid
oSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name � Certified Tester �n d a SaIV Ma
acs � , e Ct i�-L
Firm Address Casar/al)d 'T,e- -75-L 4v Cert. Tester No. &P06 t0T 73 Date C1,
Gauge #37 Z 3 53
Date last accuracy tested / • �2 Z • r_3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy