2013_0628 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baci flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
�
Manufacturer 14 - -LTA Size
Model Number D 0-7X4 -I-- Located At
Serial Number x.21 "1 7 6
The above is certified to be true.
Firm Name A i M cu-
Firm Address,, _
Gauge # Gb o-(
Date last accuracy tested +, r ?J
Certified Tester A4
Cent. Tester No. & -nn0P 7n-- Date
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
nsid
Tight
RP -o_� psid
Leaked ❑
�'
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed not o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name A i M cu-
Firm Address,, _
Gauge # Gb o-(
Date last accuracy tested +, r ?J
Certified Tester A4
Cent. Tester No. & -nn0P 7n-- Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy