2013_0122 (7)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 bad-Low 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 ( ev P g
Model Number r),-c 0, b
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size 1
Located At ? `� .1 �c� Jr,�,C e , �-L Va s�r
The above is certified to be true.
Firm Name T �.c�r� 4a2-- �.d
Firm Addres s 75 v �l U
Gauge # 5 ? Z 3 S' 3
Date last accuracy tested 1 Do) ° 13
Certified Tester 7i'�G�?.i c311/�7C�ZsV
Cent. Testier No.6 PLb 1 L 1 "13 Date C1
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 a
Opened at
Opened at
osid
Tight n
RP- ( , Dsid
Leaked ❑
Leaked o
c)
osid
osid
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP Sid
The above is certified to be true.
Firm Name T �.c�r� 4a2-- �.d
Firm Addres s 75 v �l U
Gauge # 5 ? Z 3 S' 3
Date last accuracy tested 1 Do) ° 13
Certified Tester 7i'�G�?.i c311/�7C�ZsV
Cent. Testier No.6 PLb 1 L 1 "13 Date C1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy