2013_0912CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC"IOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
LOCATION OF SERVICE:
JL 1
tl
Relief Valve
Air Inlet
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.
14
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
tUif f 1s-
e� C % fu l
Serial Number /17
S
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
r�
Size
Located At
The above is certified to be true.
Firm Name C' f� /�/ t Certified Tester c L iii' s
� > 77 7 Lv; � TX CerL Taster No. Py "4��' JC -z Date l J
Firm Address * /.'
Gauge # Lr �' -,// a t
Date last accuracy tested q- ._ /"3r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
tl
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Close
Closed Tight C3
Opened at
Opened at
oSid
Tight ❑
Leaked
Sid
oSid
RP-
__psid
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name C' f� /�/ t Certified Tester c L iii' s
� > 77 7 Lv; � TX CerL Taster No. Py "4��' JC -z Date l J
Firm Address * /.'
Gauge # Lr �' -,// a t
Date last accuracy tested q- ._ /"3r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy