2013_0122 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE (
BACICFLOW 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
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturers `� Size
Model Number Located At ( i 0A
Serial Number
The above is certified to be true.
Firm Name7'"
1 Z44
Firm Address -75-c),16
Gauge #,372-35-3
Cert. Tester N , 10773 Date 9d5-,'.ac/3
Date last accuracy tested % - 2 2 - 2 0/,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
DC- Closed
Closed Tight W
Opened at
Opened at
vsid
Ti �i �T
Leaked ❑
vsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Name7'"
1 Z44
Firm Address -75-c),16
Gauge #,372-35-3
Cert. Tester N , 10773 Date 9d5-,'.ac/3
Date last accuracy tested % - 2 2 - 2 0/,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy