2013_0716 (23)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICEA� u,'4y,:--,.. ve rc j4c•SG /31.3 �A 141 7SD/
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
2�
Double Check Valve
Manufacturer /A J
Model Number 2 �� K
Serial Number ED 3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C, Atmosphere Vacuum Breaker
Size
Located At r) !
) &
The above is certified to be true.
Firm Namq&
Firm Address IA&
X
Gauge #
Date last accuracy tested 1G %C?
r S/rl�a
Certified Tester
Cert. Tester No. G 9 Date 71��
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 2'
Opened at
Opened at
osid
Tigh� C]
RP- J � Dsid
Leaked ❑
Leaked ` ❑
5
osid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Namq&
Firm Address IA&
X
Gauge #
Date last accuracy tested 1G %C?
r S/rl�a
Certified Tester
Cert. Tester No. G 9 Date 71��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy