2013_0122 (25)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE A
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: c_ Sic? -/eS Of Vic- V30e/l /007 - �- /x/�rxf
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
PL. Double Check Valve
Manufacturer 1 v'ti� C=
Model Number C
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
+c
Size
Located At t a'� F C' c°« 4 �'�c" e
The above is certified to be true.
Firm Name Certified Tester 7 brIlI h DGCI
62966 Ge
Firm Address ? Sv 4 C) Cem Tester No, �9D l6 7 7 3 Date '/ , a S C 3
Gauge # 37 Z 3 5---s
Date last accuracy tested / - D g, � j3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight IM
Opened at
Opened at
nsid
Tight V
RP -psid
�;ed ❑
Leaked ❑
osid
nsid
Did not Open C3
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
nsid
vsid
RP sid
The above is certified to be true.
Firm Name Certified Tester 7 brIlI h DGCI
62966 Ge
Firm Address ? Sv 4 C) Cem Tester No, �9D l6 7 7 3 Date '/ , a S C 3
Gauge # 37 Z 3 5---s
Date last accuracy tested / - D g, � j3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy