2013_0122 (20)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACMOW 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 (� AA,,..
Model Number (9t
Serial Number 0S a C�
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located Ate C_f ='��
The above is certified to be true.
Firm Nam
Firm Addressa�C1° .mac 7 S O g V
Gauge # 3'-? a 3 S 3
Date last accuracy tested / . a , l 3
Certified Tester ni G- C %6,
Cent. Tester No Date `l , a 5 ' 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 T
Opened at
Opened at
osid
'PC,5
Tight ❑
RP
Leaked ❑
osid
nsid
5
-_L
Lea;ed ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Nam
Firm Addressa�C1° .mac 7 S O g V
Gauge # 3'-? a 3 S 3
Date last accuracy tested / . a , l 3
Certified Tester ni G- C %6,
Cent. Tester No Date `l , a 5 ' 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy