2013_0122 (11)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICFLOW 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.
C Reduced Pressure Principle
X Double Check Valve
Manufacturer ()�-- VI-1— C--=
Model Number ,�2cc cl, 1`
Serial Number ) 0 k
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
n Atmosphere Vacuum Breaker
Size
Located At Z p�
The above is cerdfied to be true.
Firm NamAla
Firm Address
Gauge #, D,235-5
Certified Tester J.'Z.,j
Cert. Testa N.,W- 0 10773 Date y 09 013
Date last accuracy tested - - ac 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 is
Opened at
Opened at
oSid
Tight �s
RPQ,2.psid
Leaked ❑
Leaked ❑
nSid
nSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Agar
DC- Closed
Closed not o
Opened at
Opened at
oSid
Repair
Tight ❑
nsid
nSid
RP sid
The above is cerdfied to be true.
Firm NamAla
Firm Address
Gauge #, D,235-5
Certified Tester J.'Z.,j
Cert. Testa N.,W- 0 10773 Date y 09 013
Date last accuracy tested - - ac 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy