2013_0517 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
! f ,
y
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.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
-/, t �
Model Number t ) %0 Z
Serial Number l / I i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
i"
The above is certified to be true.
Fuza Nacre
�S /��(lGt✓ Certified Tester
Firm Address 7 ,L. ' Cert. Testa No. Date /
Gauge # t
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
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight/ ❑
Leaked ❑
osid
nsid
RP- ,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Fuza Nacre
�S /��(lGt✓ Certified Tester
Firm Address 7 ,L. ' Cert. Testa No. Date /
Gauge # t
Date Last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy