2013_0122 (36)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
-I.
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 PrinciDle
Is Double Check Valve
Manufacturer If y-k- E `>
Modes Number a���
Serial Number I , i b J
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
. G
Size
Located At C {`�l - r7c'1`?/' ✓1�= r`'C'�' )� �ti��:
The above is certified to be true.
Firm N=49 40U JJS2 Certified Tester ` 7' l�lC Cr/YIIl G� L0
Firm A °75 D V v Cert. Tester No,��'L�� %c'! 77 3 Date
Gauge # 3 '1 'Z 3 5` 3
Date last accuracy tested
/ /3
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
?
Tight IE
RP- 1 . alDsid
Leaked ❑
Leaked ❑
nsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight E3
asid
nsid
RP std
The above is certified to be true.
Firm N=49 40U JJS2 Certified Tester ` 7' l�lC Cr/YIIl G� L0
Firm A °75 D V v Cert. Tester No,��'L�� %c'! 77 3 Date
Gauge # 3 '1 'Z 3 5` 3
Date last accuracy tested
/ /3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy