2013_0122 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE L�—
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
- /D O
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
�a
Double Check Valve
Manufac=er
Model Number
Serial Number l
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
IN
Size
Located At
0 L_
The above is certified to be true.
Gauge #�7a3 s3
Date last accuracy tested /-, ?o? -,:V 6i3
MA
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 A
Opened at
Opened at
---flssid
R55
Tight )r
RP -2- L psid
Leaked o
Leaked ❑
csid
_osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight C3
I
_osid
osid
RP sid
The above is certified to be true.
Gauge #�7a3 s3
Date last accuracy tested /-, ?o? -,:V 6i3
MA
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy