2013_0122CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ``
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
- 100 " ( m
PRESSURE VACUUM BREAKER
The baclflow
prevention assembly detailed below has been tested and maintained as required
by TNRCC
regulations and
is certified to be operating within
acceptable parameters.
1st Check
2nd Check
TYPE OF ASSEMBLY
Air Inlet
C
Reduced Pressure Principle
a Pressure Vacuum Breaker
Closed Tight Z
Leaked o
j
A
Double Check Valve
❑ Atmosphere Vacuum Breaker
Reps
Manufacturer
rA- C 115
Size
Model Number
C� �3
Located At
Materials
Serial Number
) Ici -5
The above is certified to be true.
Firm Name Q 41,u J Certified Tester:z �aAtLa Baia CJ42xc_1/
Firm Address ��-P el S-v * Cent. Tester No.f 60lC 17 3 Date
Gauge # 3 72 3 S 3
Date last accuracy tested j "a a ° ! 3
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
P-6'�z
DC- Closed
Tight M
RP- ,L sid
Leaked ❑
Closed Tight Z
Leaked o
j
Opened at
vsid
Opened at
nsid
Did not Opera ❑
nsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
nsid
nsid
RP sid
The above is certified to be true.
Firm Name Q 41,u J Certified Tester:z �aAtLa Baia CJ42xc_1/
Firm Address ��-P el S-v * Cent. Tester No.f 60lC 17 3 Date
Gauge # 3 72 3 S 3
Date last accuracy tested j "a a ° ! 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy