2013_0122 (33)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE x
BACXTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
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
M
Double Check Valve
Manufacturer
"
�N d F' J
r�
Model Number
Serial Number
13 C, �a D
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
i��
Size I
Located At C-A c: e ti ck o C
The above. is certified to be true.
Firm Nxa rir a, 4 Certified Tester od c
20 - C'A 7-i.!
Firm Address G-ra r 6 o d t c -7 S b g O Cent. Tester No.6006%,0 7 73 Date 9, f5-,
/3
Gauge # 2'-'7 2 3:5 3
Date Last accuracy tested / - Q a , /
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 )S-
Opened at
Opened at
nsid
�a
Tight Ik
1 -
Leaked o
osid
nSid
ct j
RP- psid __ri
Leaked ❑
Did not Open o
Leaked J
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above. is certified to be true.
Firm Nxa rir a, 4 Certified Tester od c
20 - C'A 7-i.!
Firm Address G-ra r 6 o d t c -7 S b g O Cent. Tester No.6006%,0 7 73 Date 9, f5-,
/3
Gauge # 2'-'7 2 3:5 3
Date Last accuracy tested / - Q a , /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy