2013_0122 (14)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE Y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly detailecrbelow has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
� Double Check Valve
Manufacturer 0, y')�v
Model Number
Serial Number C-' 55 C C
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At ) CJ a� C- L \ c i C-
The above is certified to be true.
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
.Xe X5-0540
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
C Gj
DC- Closed
Tight
RP- t psid
Leaked ❑
Closed Tight 7a,
Leaked ❑
Opened at
nsid
Opened at
nsid
Did not Open ❑
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
__nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Nam
01 �O S
Firm Address
.Xe X5-0540
Gauge # 373 S3
Date last accuracy tested % I a;9 - j 3
L w-Jes W-AWFAI M�f,
Cat Tester No4A NO -713 Date Cl ` a S-' 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy