2013_0122 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACxnow PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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 Principle
Double Check Valve
Manufacturer =n'1
Model Number C
Serial Number Cr-
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At -a'd� C�� n C �� 6 J�
The above is certified to be true.
Firm Name Gt J 0 Certified Tester `� a4t t,art.. C1
aav� .1 ck
Firm Address �c .� cj - -7 Sv q O Cert. Tester No. I � 10`17 � Date ' �� �` I
Gauge # '3 -7 2 3 S 3
Date last accuracy tested
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 `Q�
Opened at
Opened at
osid
J
Tight
RP- j y sid
Leaked ❑
Leaked ❑
osid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
______p sid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name Gt J 0 Certified Tester `� a4t t,art.. C1
aav� .1 ck
Firm Address �c .� cj - -7 Sv q O Cert. Tester No. I � 10`17 � Date ' �� �` I
Gauge # '3 -7 2 3 S 3
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy