2013_1202CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKF'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ✓ 7, 0�
The bacltilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number Ml A 2424
Serial Number '' ,' // y
Size
Located At
The above is certified to be true.
Firm Name ro relIAA -" Certified Tester ,5' i! ✓�
Firm Address Cert. Tester No. Date Z-
Gauge #
Date last accuracy tested f 7.2,0/3
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
2.20/3
DC- Closed
Tight ❑
RP- Z psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name ro relIAA -" Certified Tester ,5' i! ✓�
Firm Address Cert. Tester No. Date Z-
Gauge #
Date last accuracy tested f 7.2,0/3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy