2013_0517 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ;'f % //� ��,f f 1 { `�'��► I,_
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number U7-7 A j
Serial Number r
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size L
Located At
The above is carfinfied�o be true.
dFirm Name Name Certified fied Test � f L
Firm Address L/ i �' Cent. Testa No.� { Date
Gauge #
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 "I'
-7 Dsid
Leaked ❑
osid
osid
Lea;ed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is carfinfied�o be true.
dFirm Name Name Certified fied Test � f L
Firm Address L/ i �' Cent. Testa No.� { Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy