2013_0716 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICERA -,5
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C7 Atmosphere Vacuum Breaker
Manufacturer �� S Size
Model Number S cx</ Located At
Serial Number
The above is certified to be true.
Firm Name ro L. cim m . Certified Testa e Y rc4 �2,4 na.-
Firm Addre ,00^ 12 c 1 h,L' Cert. Tester No.SAAM%6 69 Date
Tk 7 6��j
Gauge # D ,9�
Date last accuracy tested /Q� /Z
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
vsid
Tight
RP -_psid
Leaked ❑
vsid
vsid
Lccaed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Name ro L. cim m . Certified Testa e Y rc4 �2,4 na.-
Firm Addre ,00^ 12 c 1 h,L' Cert. Tester No.SAAM%6 69 Date
Tk 7 6��j
Gauge # D ,9�
Date last accuracy tested /Q� /Z
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy