2013_0415 (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 back low 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
C/ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer i� cn Size Z9
L ` If
Model Number �S& Located At 9/ `� AJT azn - Ayzye- -S7'�
Serial Number FG3/ 7- / / /6 SS
The above is cerdfied to be true.
Firm NameA . 00';-%V S ��=f' C. Certified Tester
Firm A ,9,Qe.x t Testa No. MV ' `� Date
Aer&S
Gauge # 6 p C
Date last accuracy tested / 7 ._/ 2 --/ 'L-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 2r
Opened at
Opened at
oSid
V-5s-RP-
Tight ,3 - 'L
_L,psid
Leaked ❑
Leaked i o
osid
oSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight ❑
osid
osid
RP sid
The above is cerdfied to be true.
Firm NameA . 00';-%V S ��=f' C. Certified Tester
Firm A ,9,Qe.x t Testa No. MV ' `� Date
Aer&S
Gauge # 6 p C
Date last accuracy tested / 7 ._/ 2 --/ 'L-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy