2013_0122CHECK ONE:
IRRIGATION DOMESTIC FIRELINE >.
BACXFLOW 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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
`s Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer A4kv eC 3 Size
Model Number �� � Located At 1 I b3_ a?� v1c' e �--te:C 2 C _
Serial Number 1
The above is certifier) to be true.
Firm Name � ��
Firm Address ,8a4 a-Nth 7 5-c) 4 U
Gauge # 3 12,2 3,5-3
Date Last accuracy tested f - d 2, /3
Certified Tester'-f- )
Cert Tester NwQ PC S /6 7-13 Date 9,,;2 5- /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 I&
Opened at
Opened at
nsid
P, :Z
Tight >g
RP -2, nsid
Leaked ❑
Leaked ❑
mt�?
osid
_nsid
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certifier) to be true.
Firm Name � ��
Firm Address ,8a4 a-Nth 7 5-c) 4 U
Gauge # 3 12,2 3,5-3
Date Last accuracy tested f - d 2, /3
Certified Tester'-f- )
Cert Tester NwQ PC S /6 7-13 Date 9,,;2 5- /3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy