2013_0122 (41)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE_ ,
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
/00 -7
The bac0ow 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
Z Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 1 �,- Size
Model Number �=�� '% Located At
Serial Number , 1
The above is certified to be true.
Firm NaMA2Ua2aZ41111 ). 4 1' Certified Tester =a-114n sZ'OdO
Firm Addrm b � z;61 -Z-k . 7 5 ° * u Cent. Tester No `7 7.3 Date C1 '0- 5 I
Gauge # 3 ? 2 3 5 3
Date Last accuracy tested / • �) � • 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
4�J
DC- Closed
Tight c� B
RP- t� •P psid
Leaked ❑
Closed Tight 19
Leaked ❑
Opened at
vsid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vsid
Opened at
osid
_ nsid
RP sid
The above is certified to be true.
Firm NaMA2Ua2aZ41111 ). 4 1' Certified Tester =a-114n sZ'OdO
Firm Addrm b � z;61 -Z-k . 7 5 ° * u Cent. Tester No `7 7.3 Date C1 '0- 5 I
Gauge # 3 ? 2 3 5 3
Date Last accuracy tested / • �) � • 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy