2013_0122 (6)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
r Double Check Valve
Manufacturer )A wt. E S
Model Number CC,-, C, 6
Serial Number i I �--,-
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At /6 3 A -J e-o a JaAc ✓� `c s4rC� C.
The above is certified to be true.
Firm Name alt at cLc" �2e
qb
Firm Addn=- ,B0-4y0,-v? ° y So
Gauge # 3 7 2 3 5-3
Date last accuracy tested J' D Q- i3
CUUM BREAKER
Check Valve
osid
Leaked ❑
osid
Certified Tester `�'2t� c- �C�/Y��
Cert. Tester No.6fe6 I a 77-3 Date C1 '19 S • 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VA
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight ;r
psid
Leaked ❑
Closed Tight A
Leaked ❑
y
Opened at
osid
Opened at
osid
Did not Open ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
osid
Opened at
osid
RP sid
The above is certified to be true.
Firm Name alt at cLc" �2e
qb
Firm Addn=- ,B0-4y0,-v? ° y So
Gauge # 3 7 2 3 5-3
Date last accuracy tested J' D Q- i3
CUUM BREAKER
Check Valve
osid
Leaked ❑
osid
Certified Tester `�'2t� c- �C�/Y��
Cert. Tester No.6fe6 I a 77-3 Date C1 '19 S • 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy