2013_0122 (42)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW 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.
C Reduced Pressure Principle
Z, Double Check Valve
Manufacturer 61 C
Model Number t U C, 0
Serial Number (�o��
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
a�
Size
Located At 1 1-�t �1e-e_yre't GcjN._
The above is certified to be true.
Firm Nami'AAA4 cz r c 61U
�
Firm Address -,2"evy/ •-I-X 2 S 24 �)
Gauge #32 J 3 5 3
Date last accuracy tested / - 0 Q - /3
Certified Tester` /i�c�
Cent, Testa NoA D0 P 77 _:� Date f 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 V,
Opened at
Opened at
osid
Tight �s
Leaked C3
Sid
oSid
i`' ,a. 5
k- LLpsid
Leaked ❑
9
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Nami'AAA4 cz r c 61U
�
Firm Address -,2"evy/ •-I-X 2 S 24 �)
Gauge #32 J 3 5 3
Date last accuracy tested / - 0 Q - /3
Certified Tester` /i�c�
Cent, Testa NoA D0 P 77 _:� Date f 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy