2013_0604CHECK ONE:
IRRIGATIONiA— DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention asscm`W detailed below has been tested
regulations and is certified to be operating within acceptable parameters.
` J Reduced Pressure Principle
Double Check Valve
Manufacturer t
Model Number oc :j
Serial Number
required by TNRCC
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
1.
Size
Located At
The above is certified to be true. �-7- --
Firm N &W Certified Tester
Firm A E' it bAe-Ccm Tester No. Q'q :�Q Date
Gauge #
Date Last accuracy tested �P,_
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
Tight
Closed Tight )t`1
Leaked ❑
Opened at
osid
Opened at
nsid
nsid
RP- i--D—psid�
Leaked ❑
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true. �-7- --
Firm N &W Certified Tester
Firm A E' it bAe-Ccm Tester No. Q'q :�Q Date
Gauge #
Date Last accuracy tested �P,_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy