2013_0912 (2)CHECK ONE:
IRRIGATION jC
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 terrified to be operating within acceptable parameters.
C Reduced Pressure Principle
�t Double Check Valve
Manufacturer -/ -C b �- c�,
Model Number Y
Serial Number X
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C7 Atmosphere Vacuum Breaker
e7 �
Size "p
Located At
The above is certified to be true.
Firm Name ���� :t �''r` Certified Tester
,r'� %. �3 X �� � ? , ✓' � � �v��y, ; Vic:' .
Firm Address Cent. Testa No. Date
Gauge # / 7 � 0
Date last accuracy tested 'Y
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
I .>
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight .10
Leaked 2. 0 ❑
Opened at
nsid
Opened at
nsid
nsid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ���� :t �''r` Certified Tester
,r'� %. �3 X �� � ? , ✓' � � �v��y, ; Vic:' .
Firm Address Cent. Testa No. Date
Gauge # / 7 � 0
Date last accuracy tested 'Y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy