2013_0204 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACK{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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 W"4
Model Number p0 `7",
Serial Number p �!
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At A/. 5, d
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
White — Customer's Copy
Certified Tester
Cert. Tester No.
Yellow — City Copy
Date
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
nsid
Tight ❑
Leaked ❑
psid
nsid
RP - _psid
beaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
n sid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date Last accuracy tested
White — Customer's Copy
Certified Tester
Cert. Tester No.
Yellow — City Copy
Date
Pink — Tester's Copy