2013_0204 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: Z r7
The back -low 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 ' J' �' • ~= '�
Model Number b
Serial Number , 56
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size
d�
Located At ��• -'
The above is certified to be true.
Firm Name
Firm Address
Gauge # ,
Date last accuracy tested %- 3 t - 17
Certified Tester :' .o
Cent. Testa No. '3 P,. -ua l Date
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 Ld
Opened at
Opened at
vSid
Tight ❑
Leaked ❑
vsid
vSid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vSid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # ,
Date last accuracy tested %- 3 t - 17
Certified Tester :' .o
Cent. Testa No. '3 P,. -ua l Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy