2013_0122 (28)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE )(
BACXFLOW 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
jr- Double Check Valve
Manufacturer ^'
e
Model Number �-
Serial Number)
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
�. i'j
Located At ' �! C3",,N�� C2 a%i �Z,
The above is certified to be true.
Firm Name A/2cz g 4W' -2 - Certified Tester `n2ad -z1y Jandaml
Aacs y�Za&- C -
Firm Address '-7-67e Cat. Tester No.AAZ)0 /-a 7 7 3 Date �f ' 5- ./3
Gauge #31-9-353
Date last accuracy tested / • 0 a - 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
nsid
M
RP -L-1ULpsid
Leaked ❑
nsid
nsid
Leaked Cl
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name A/2cz g 4W' -2 - Certified Tester `n2ad -z1y Jandaml
Aacs y�Za&- C -
Firm Address '-7-67e Cat. Tester No.AAZ)0 /-a 7 7 3 Date �f ' 5- ./3
Gauge #31-9-353
Date last accuracy tested / • 0 a - 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy