2013_1025CHECK ONE:
IRRIGATION__ DOMESTIC FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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 Check Check Valve
Manufacturer
Double Check Valve Assembly
Model Number
b
Serial Number
f I�� �,�) I
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size -311
Located At uhifld W( � `k y
The above is certified to be true.
Firm Name & dj�. Certified Tester t1f
Firm Address WA C U 1�1l 1t ;� j.� t Cert. Tester No. Date
�l
Gauge #�J 122j _
Date last accuracy tested
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 'ji
Opened at
Opened at
osid
Ti
Leaked ❑
nsid
vsid
RPpsid
2 -101
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_psid
Repair
Tight ❑
psid
vsid
RP sid
The above is certified to be true.
Firm Name & dj�. Certified Tester t1f
Firm Address WA C U 1�1l 1t ;� j.� t Cert. Tester No. Date
�l
Gauge #�J 122j _
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy