2013_1105 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINEZ41k-L—
BA OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # A
LOCATION OF SERVICE: Ij
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 C Pressure Vacuum Breaker
Double Check Valve 11 Atmosphere Vacuum Breaker
Manufacturer W& Size -3/w
Model Number lo Located At T?i VMk1 4-
Serial Number L% -() �
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMEBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check-
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closed
Closed Tight
9!('
Opened at
Opened at
osid
Tight &I'
Leaked
0
—psid
------_psid
Iti-IL—i-psid
&�,,
Leaked 0
Did not Open 0
Leaked 13
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight
0
Opened at
Opened at
Repair
Tight 0
________psid
psid
I RP nsid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy