2013_0122 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE /\ __
BACMOW 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
Double Check Valve
Manufacturer
Model Number �,�-
Serial Number )
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
,,
Size
Located At b �—+ L took cGr
N
The above is certified to be true.
Firm Name
�Q5 0�i iG tom• T,�/
Firm Address E 44-t� ra r /rvn
"754)40
Gauge # 3'7 95 S3
Date last accuracy tested % , 01 QQ ° 13
Certified Tester )'d/-)C 0 k21
Cert. Tester No. - Q/ 6 7 73 Date 9'2- S-- /S
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 15,
Opened at
Opened at
psid
`� j`✓`
Ti m AZ-
RP --I C psid
Leaked C3
Dsid
psid
Leaked ❑
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name
�Q5 0�i iG tom• T,�/
Firm Address E 44-t� ra r /rvn
"754)40
Gauge # 3'7 95 S3
Date last accuracy tested % , 01 QQ ° 13
Certified Tester )'d/-)C 0 k21
Cert. Tester No. - Q/ 6 7 73 Date 9'2- S-- /S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy