2013_0122 (11)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE �M7
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
WA -101'A
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's
E,
Model Number
Serial Number`
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 1
Located At
The above is certified to be true.
Firm Nam
as us
Firm Address Nt & ��Jlz '7 1&46 -)
Gauge #3 7c9 3 3
Certified Testae
Cat. Testa No.,9&0 /0 7 7 3 Date 5 U! 3
Date Last accuracy tested/ - 2 2 - ,:P o 1 `3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Tight k
RP- _ " sid
Leaked ❑
Closed Tight A
Leaked ❑
Opened at
nsid
Opened at
osid
Did not Open ❑
flsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight Cl
Closed Tight o
Opened at
osid
Opened at
osid
sid
Rp sid
The above is certified to be true.
Firm Nam
as us
Firm Address Nt & ��Jlz '7 1&46 -)
Gauge #3 7c9 3 3
Certified Testae
Cat. Testa No.,9&0 /0 7 7 3 Date 5 U! 3
Date Last accuracy tested/ - 2 2 - ,:P o 1 `3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy