2013_0628CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �a (,L%i S. 2"., L
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
Af Double Check Valve
Manufacturer !
Model Number 10
Serial Number 11,1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At A/ LJ V,c 1-i"
The above is certified to be true.
n
Firm Name !`leh-
jor , - _
Firm Addr ss� a i�r c �j %
GJ4X�L+4c Y> '% 77 1
Gauge # 0�0
Date last accuracy tested
Certified Tcster AA I Ky— 01 1 I� rte► 5
Cat. Testa No. t M v ~ 61 Date U z
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
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 0
Opened at
Opened at
oSid
Tight ,. Z
RP- ✓_=� Dsid
Leaked ❑
S
Lal
nSid
oSid
�;� ❑
Did not Open o
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.
n
Firm Name !`leh-
jor , - _
Firm Addr ss� a i�r c �j %
GJ4X�L+4c Y> '% 77 1
Gauge # 0�0
Date last accuracy tested
Certified Tcster AA I Ky— 01 1 I� rte► 5
Cat. Testa No. t M v ~ 61 Date U z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy