2013_0510 (4)CIIECK ONE:
IRRIGATION_ DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 5- A el
The bacltilow 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 AIA f 6
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
ii
Size
Model Number Located At
Serial Number �/ 3
-5- kt-- C.,� I xe"
The above is certified to be true.
Firm Name /��' }� o w `" /'t r Certified Tester ///` /
Firm Address r',() i36 t 7 Y 7 "-" - r^Ce t Tester Nc$ KO C l v.t Date ,S=
Gauge # o6t,7) -� / 7 iP e2
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed -;2- 0
Tight j$°
Closed Tight Ql;
Leaked /G ❑
Opened at
_osid
Opened at
osid
osid
RP- ._paid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Auer
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
_osid
_ nsid
RP sid
The above is certified to be true.
Firm Name /��' }� o w `" /'t r Certified Tester ///` /
Firm Address r',() i36 t 7 Y 7 "-" - r^Ce t Tester Nc$ KO C l v.t Date ,S=
Gauge # o6t,7) -� / 7 iP e2
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy