2013_0211 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ti
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
I
Manufacturer
Reduced Pressure Principle
Double Check Valve
W "d t1.S
Model Number 7 ?
Scrial Number % e Ll
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name �� X T Certified Tester
Firm Address ��, f01 717 '� °�" Xe ryCert. Tester No.�� �` w 7� - D� , 2
Gauge # 0 & C) y / 7K
Date last accuracy tested 7/ - /:--7 -/ �2-
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
nsid
Tight J9
Leaked .<-y -2, ❑
vsid
�osid
RP- _,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
--psi d
Repair
Tight ❑
vsid
_,_psid
RP sid
The above is certified to be true.
Firm Name �� X T Certified Tester
Firm Address ��, f01 717 '� °�" Xe ryCert. Tester No.�� �` w 7� - D� , 2
Gauge # 0 & C) y / 7K
Date last accuracy tested 7/ - /:--7 -/ �2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy