2013_0122 (27)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
6
RM
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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer puyvc r Size I
Model Number Located At i C � �� Y oLC1 ro =c
t
Serial dumber L
The above is certified to be true. 1
Firm Nand r_T
Firm Address X 7 5v40
Gauge # 3-7 2 3, 3
Date last accuracy tested % ' 2 2 , 13
Certified Tester /) /dt-1 n
Cert. Tester No 62 a l b '7 73 Date --f ` 2 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 Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
`5'
DC- Closed
Tig 'Vr
RP- sid
Leaked D❑
Closed Tight ia-
Leaked ❑
,
Opened at
DSid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
ght 13
LR C- Closed
Closed Tight C3
Opened at
Sid
Opened at
oSid
oSid
P s id
The above is certified to be true. 1
Firm Nand r_T
Firm Address X 7 5v40
Gauge # 3-7 2 3, 3
Date last accuracy tested % ' 2 2 , 13
Certified Tester /) /dt-1 n
Cert. Tester No 62 a l b '7 73 Date --f ` 2 5-,13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy