2013_0122 (9)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW 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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
e Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer a vv\� e -5 Size
Model Number Located At
Serial Number U j
The above is�certified to be true.
Firm Names"
a z a s- CIO_ aGr,t.
Firm Address
Gauge # 3 7,:;� SW ?,
Certified Tester Janrjm3n
Cert. Taster No,64101 7 73 Date `I ° a 5 •a 6 J 3
Date last accuracy tested / - j R - :;2 U % 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 OK
Opened at
Opened at
osid
Tight
Leaked ❑
osid
osid
pa, j
RP- Dsid
a , (�
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
osid
osid
RP psid
The above is�certified to be true.
Firm Names"
a z a s- CIO_ aGr,t.
Firm Address
Gauge # 3 7,:;� SW ?,
Certified Tester Janrjm3n
Cert. Taster No,64101 7 73 Date `I ° a 5 •a 6 J 3
Date last accuracy tested / - j R - :;2 U % 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy