2014_0103 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW 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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve I pe.fecler. ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At�►,.� .
Serial Number
The above is certified to be/'�true.
Firm Name: 9 t f j : r e Fir o i Certified Tester • "� fie. ►`,
Firm Address--,,// Cert. Tester No. ? a D57pate ! /
Gauge #cap
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
n 0-j
Double Check Valve Assembly
r-e
_x-f
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
oSid
Tight o
Leaked o
osid
nSid
RP -_psid
Leaked ❑
Did not Open o
Leaked o
Repairs
4 -1' sALAi
v-W ✓0%1v
l-5-,�Ckl^
b/0wr,
"-t
and
Materials
'''`raj e r
�► a a�s o
6 e. s 1.
o -�` c}
174 c
Used
,, , 4 - '1`
�1e.4� 1-f t
;,
i' r r' P. r e r'
i r ._
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nSid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be/'�true.
Firm Name: 9 t f j : r e Fir o i Certified Tester • "� fie. ►`,
Firm Address--,,// Cert. Tester No. ? a D57pate ! /
Gauge #cap
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy