2013_0913 (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW 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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer S
Model Number
Serial Number �� J
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size J`
Located At /r/ 'ele
The above is cctified to be true.
Firm Name / y i e �� �— �f C �" Certified Tester %� � W,
Firm Address PG', d cc X 7 Z 7 .� T"Cert. Tester NollOO&C, Date
Gauge # 0 & C1 -J / 7 � l.?
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
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight /• Y Y
Closed Tightl
Leaked /, ❑
Opened at
nsid
Opened at
vsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is cctified to be true.
Firm Name / y i e �� �— �f C �" Certified Tester %� � W,
Firm Address PG', d cc X 7 Z 7 .� T"Cert. Tester NollOO&C, Date
Gauge # 0 & C1 -J / 7 � l.?
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy