2013_0122 (19)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKnOW 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.
❑ Reduced Pressure Principle
❑
Double Check Valve
,/
Manufacturer i "�C:.fy' �'-
Model Number-
Serial Number��
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At ' (% C r.� G.1, a-
The above is certified to be true.
Al? /
Firm Name �" a AWf Certified Testa
Laos e .
'
Firm Address r� J--t --7,5-0 '40 Cat. Testa Noh0d01l1 `17 3 Date a 3
Gauge # 3'7 2 3 S 3
Date last accuracy tested j • a ,;� - B
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 1&
Opened at
Opened at
nsid
Tight ID
Leaked ❑
Leaked ❑
Dsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_______.p sid
Repair
Tight ❑
nsid
vsid
RP sid
The above is certified to be true.
Al? /
Firm Name �" a AWf Certified Testa
Laos e .
'
Firm Address r� J--t --7,5-0 '40 Cat. Testa Noh0d01l1 `17 3 Date a 3
Gauge # 3'7 2 3 S 3
Date last accuracy tested j • a ,;� - B
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy