2014_0204CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACETLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
A V��
C(
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufactur L�
er
Model Number) -7
Serial Number
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmo here Vacuum Breaker
t L
Size
Located At j(�' l i PV7
The above is certified to be true.
r
Firm Name e )(a5 d ) ud Certified Testa -J40)"
� S
Firm Address ^� 1'��at Testa No Date
Gauge # 00 - 1
Date last accuracy tested
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 ❑
Opened at
Opened at
vsid
Tight ❑
Leaked ❑
Dsid
vsid
RP -_psid
Leaked
Did not Open ❑
Leaked O
Reps
and
(? .
Materials
Used
Test After
DC- Closed
Closed Tight >
Opened at
Opened at
_vsid
Repair
Tight
< < ;>
vsid
psid
RP sid
The above is certified to be true.
r
Firm Name e )(a5 d ) ud Certified Testa -J40)"
� S
Firm Address ^� 1'��at Testa No Date
Gauge # 00 - 1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy