2013_0820CHECK ONE:
IRRIGATION_ DOMESTIC FIRELINE
-C,i✓ - 13 -3 94 7
BACK MOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 713 1`. t ',,A6-no-J+ f c
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.
❑.0 Reduced Pressure Principle
Y' Double Check Valve
Manufacturer J,01,- 1 V� t h e
Model Number
Serial Number 9 12 ?t
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size /C4 - -
Located At 6`)
The above is certified to be true.
Firm Name
Firm Address N)
Gauge #
Date last accuracy tested
Certified Tester ' ' " ° ,� h , 1 r
Cent. Tester No. Date
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 ❑
Opened at
Opened at
osid
Tight ❑
Lcaiced ❑`
Leaked ❑
•
osid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Q-
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
�nsid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address N)
Gauge #
Date last accuracy tested
Certified Tester ' ' " ° ,� h , 1 r
Cent. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy