2013_0122 (10)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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer
Model NumberL
Serial Number" Ell
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
4�
Size `
Located At ) � 53 �a�� y-;� vole _d` c q ; ✓� r t;
CUUM BREAKER
Check Valve
asid
Leaked ❑
__ osid
The above is certified to be true.
Firm Name c Certified Tester�/��
i"
Firm Address �f c � z� l.7-SL R`` / Cent. Tester No b/ (',61C L3 Date '�/
Gauge # _ 3 2 2. 3 , >
Date last accuracy tested
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
Closed Tight 1A
Opened at
Opened at
Tight 11g
Leaked ❑
asid
asid
5 j
RP- Lpsid
leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
Repair
Tight ❑
asid
asid
RP sid
CUUM BREAKER
Check Valve
asid
Leaked ❑
__ osid
The above is certified to be true.
Firm Name c Certified Tester�/��
i"
Firm Address �f c � z� l.7-SL R`` / Cent. Tester No b/ (',61C L3 Date '�/
Gauge # _ 3 2 2. 3 , >
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy