2013_0913CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
14 Double Check Valve
Manufacturer a`r'k } /,s
Model Number C)6, 7 1--f ;7-
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 3`l
Located At ��`' G fJ Tf rt,
The above is certified to be true.
Firm Name /1c A/1', `t' r ✓ yt Certified Tester
Firm Address C- /3c, 7' % ` 7 1�/,,l M- Ceert. Tester No. /*0 f'c t' Date
Gauge # e U d cl / 7 t t
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 ,
Tight ,2 _ l3
Closed Tight t4,
Leaked -J e ❑
Opened at
oSid
Opened at
oSid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name /1c A/1', `t' r ✓ yt Certified Tester
Firm Address C- /3c, 7' % ` 7 1�/,,l M- Ceert. Tester No. /*0 f'c t' Date
Gauge # e U d cl / 7 t t
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy