2013_0122 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE tk
BACI{F'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
- / ,00
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer 4C-
Model Number��'>
Scrial Number =t
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
AN
Size
Located At g5,5
IFREDUCED
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
Opened at
Opened at
nsid
j
Tight .K'
RP -sid
Leaked ❑
Leaked ❑
vsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name -
z r os
Firm Ad&= baAZza / -.4 -7 5 -6'10
Gauge #J-2,?-3 S3
Date last accuracy tested
Cent. Tester No Date 9 o? S - of 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy