2013_0513CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:) 9 J�rU Md r
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
❑
Double Chfeck( Valve
Manufacturer i/y �� I ►' ` 1 �1 �':
Model Number 0
Serial Number A ;1,;t,57 ?
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size �,(
Located At "'WA ' ` apex '` f e ► `''
I I
The above is certified to be true.
Firm Name/, a C W
4�-
Firm Address
Gauge #
Date last accuracy tested
, f Certified Tester
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
Tight ❑
RP -_psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Reps
and
R , n G
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name/, a C W
4�-
Firm Address
Gauge #
Date last accuracy tested
, f Certified Tester
Cent. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy