2013_0715CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: -5- 5' 5 fti a 4'd G ��
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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number R5 G
Serial Number �" n 3 c Z/ X/ y
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
D Atmosphere Vacuum Breaker
.r
Size
Located At
The above is
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm Name l
c= r e- ��� Irk r
Certified Tester
1st Check:
2nd Check:
Firm Address'
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight t
Opened at
Opened at
osid
Tight � S tt
Leaked 3-,-' ❑
osid
osid
R.P -_psid
Leaked Cl
Did not Open ❑
Leaked ❑
Repairs
and
� '' Pile �±� � a e.1 �
�> s
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
The above is
terrified to be true.
Firm Name l
c= r e- ��� Irk r
Certified Tester
Firm Address'
! 3 1c 7 ` 7 G� X
if Cert Tester No. J %'' rc c ;� c -
Date 7'/ 5 /J'
Gauge # &6 e
Date last accuracy tested `` 7 / I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy