2013_0122 (38)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back -Low 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
3
Double Check Valve
Manufacturer
Model Number ac c
Serial Number I (, 0 9 L
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
.t
Size
Located At
The above is certified to be true.
Firm Name ct AZJ�G�Lt
as ea5 9 cx
Firm Addressji24t4,761..1 -x -7 5-0,4 U
Gauge # 3 *� 2-35-3
Date last accuracy tested /' 0 3 ° 13
Cut. Tester No��2107 73 Date _ S - /,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 X
Opened at
Opened at
nSid
CS
Tight RC
RP -e nsid
Leaked ❑
Leaked ❑
+ "
nSid
_ nSid
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ psid
Repair
Tight ❑
psid
vSid
RP sid
The above is certified to be true.
Firm Name ct AZJ�G�Lt
as ea5 9 cx
Firm Addressji24t4,761..1 -x -7 5-0,4 U
Gauge # 3 *� 2-35-3
Date last accuracy tested /' 0 3 ° 13
Cut. Tester No��2107 73 Date _ S - /,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy