2013_0517 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow 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
C Doub(lle Check Valve
Manufacturer W ' j
Model Number
ry)S
serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C' Atmosphere Vacuum Breaker
5 .
Size t
Located AiP
V
The above is certified to be true. /
Firm Name 0 41, Certified Tester 5
Firm Address O �� �'�/ � ` T-C- Cert. Tester No. 7 Date
Gauge # e-� C, q b L f-,
Date last accuracy tested I
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 ❑
RP- ._psid
Leaked ❑
Leaked ❑
oSid
nSid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true. /
Firm Name 0 41, Certified Tester 5
Firm Address O �� �'�/ � ` T-C- Cert. Tester No. 7 Date
Gauge # e-� C, q b L f-,
Date last accuracy tested I
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy