2013_0122 (17)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE_ )(
BACIOLOW 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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
'�f- Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer iN� E S Size l
Model Number Located At
Serial Number L(
The above is certified to be true.
Firm Name`s Certified Tester ` n t�
Firm Address -.A -t-s- Cat Testa Noc62ZLLQU3 Date I`
Gauge #,3) 23 :5-�
Date last accuracy tested % - a R • / 3
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 )a
Opened at
Opened at
osid
P,5s
Tight tR
RP -�sid
Leaked ❑
asid
oSid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nSid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name`s Certified Tester ` n t�
Firm Address -.A -t-s- Cat Testa Noc62ZLLQU3 Date I`
Gauge #,3) 23 :5-�
Date last accuracy tested % - a R • / 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy