2013_0122 (22)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE Zj
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow 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
+� Double Check Valve
Manufacturer t2 J
Model Number
Serial Number ( C L'>
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
1, \
Size
Located At
b✓
The above is certified to be true.
Firm NamcJ
aa�s c,5
Firm Address —fix ? S,) 4 0
Gauge # :31 23 5-3
Date last accuracy tested i � --'Q ° 13
Certified Tester
Cat. Testa No.6fW ! e) 713 Date ° d 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
Opened at
Opened at
nsid
o
c .5 :5
r
Tight 'S
RP -nsid
Leaked ❑
Leaked C3
nsid
nsid
Did not Open ❑
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 NamcJ
aa�s c,5
Firm Address —fix ? S,) 4 0
Gauge # :31 23 5-3
Date last accuracy tested i � --'Q ° 13
Certified Tester
Cat. Testa No.6fW ! e) 713 Date ° d 5-'13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy