2013_0913 (3)CIIECK ONE:
IRRIGATION X DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: y /Y /
The baciflow 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
S5 ' Double Check Valve
Manufacturer /^� 's'- 0
Model Number k 0
Serial Number )�-1 -21 ,j1 C
TYPE OF ASSEMBLY
❑ Pressure Vacwmn Breaker
❑ Atmosphere Vacuum Breaker
l/
Size
Located At? "'r irk +t
The above is certified to be true.
Firm Name /j'e � j c w ,-
Firm Address P4' dc - 2 -7 7 L'` I )) X x)—T'`
Gauge # e� i- C tl / 7 9 C'
Date last accuracy tested C/ ` 5- "/ .3
Certified Tester
Cat. Testa No. M" -;0 C' -0, 6L2- Date Y " ✓� yX�
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 ;? �" b
Closed Tight ;1�
Leaked �2. �2 ❑
Opened at
nsid
Opened at
nsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name /j'e � j c w ,-
Firm Address P4' dc - 2 -7 7 L'` I )) X x)—T'`
Gauge # e� i- C tl / 7 9 C'
Date last accuracy tested C/ ` 5- "/ .3
Certified Tester
Cat. Testa No. M" -;0 C' -0, 6L2- Date Y " ✓� yX�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy