2013_0912 (3)CHECK ONE:
IRRIGATION ,V DOMESTIC FIRELINE
13ACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
CITY OF COPPELL
PWS I.D. #
r
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
PRESSURE VACI
Double Check Valve
� f% f t -
Manufacturer
1st Check
2nd Check
Model Number
7 r
Air Inlet
i
Serial Number
Closed Tit J9
Leaked 74 ❑
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
:,
Size `2,
Located At
pXo K. y yf f /tTi �� k
The above is certified to be true.
Firm Name
Firm Addr= / 7 1� 7 1,61x117-7'1
Gauge # G // � G
Date last accuracy tested '�/ _ 5 __ / -?
:TOM BREAKER
Check Valve
psid
Leaked ❑
______psid
Certified Tester '` 1'14c -' ' s
Cert. Testa No. �Vec 6 0 %' l-"' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight v7- t,/ i
Closed Tit J9
Leaked 74 ❑
Opened at
psid
Opened at
osid
y
It -_psid
s f
Leaked ❑
Did not Open ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Addr= / 7 1� 7 1,61x117-7'1
Gauge # G // � G
Date last accuracy tested '�/ _ 5 __ / -?
:TOM BREAKER
Check Valve
psid
Leaked ❑
______psid
Certified Tester '` 1'14c -' ' s
Cert. Testa No. �Vec 6 0 %' l-"' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy