2013_0122 (8)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE Y
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Al Q, - Size g ,
Model Numbers Located At
Serial Number Ito I 1 c
The above is certified to be true.
Firm Name �z - y.
aao� C L71
Firm Address Aada •� sv'�v
Gauge # 3-7 13 S 3
Date last accuracy tested % a '
Cat Testa No. 6 P66 f U -1-7 Date 9 ' ,! S 13
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 Ck
Opened at
Opened at
nsid
R
Tight V
sid
Leaked ❑
nsid
nsid
65
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
vsid
RP sid-
The above is certified to be true.
Firm Name �z - y.
aao� C L71
Firm Address Aada •� sv'�v
Gauge # 3-7 13 S 3
Date last accuracy tested % a '
Cat Testa No. 6 P66 f U -1-7 Date 9 ' ,! S 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy