2013_0628 (3)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 bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
�= Double Check Valve
Manufacturer W �,- 1 :�
Model Number 0,0-7/1:1-
Serial Number SS 1 `% 3
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Located At e r- fL
The above is certified to be true.
Firm Name - ;� V.% Y t K- Pr;,
Firm Address h . ; jai ? -7
xwG.�i�t� T�, ?-0-0
Gauge # ) 7 -1 V
Date last accuracy tested Ll` j�-13
Certified Tester -J _ ad",
Cent. Testa No. jZ 7 I,7-7 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 X
Opened at
Opened at
oSid
Tight ;r
Ri -.2.2 psid
Leaked ❑
nSid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed not ❑
Opened at
Opened at
_osid
Repair
Tight ❑
nsid
_pSid
RP sid
The above is certified to be true.
Firm Name - ;� V.% Y t K- Pr;,
Firm Address h . ; jai ? -7
xwG.�i�t� T�, ?-0-0
Gauge # ) 7 -1 V
Date last accuracy tested Ll` j�-13
Certified Tester -J _ ad",
Cent. Testa No. jZ 7 I,7-7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy