2013_0318CHECK ONE:
IRRIGATION
DOMESTIC
r
i
i
FIRELINE" j
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacdlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
0, Reduced Pressure Principle
jV Double Check Valve
Manufactimer
Model Number ?�
Scrial Number 1 a Ce
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 1 } ` U b
Located At
The above is certified to be true.
Firm Name (1Y ►�� Vr4zclpf1 Catified Tester
Firm Address N I- n iThQn (, Cat. Tester No Date ,S
64 P� I _�-, 0 N I.
Gauge # 0Q0 I
Date last accuracy tested J2 �� 3
White - Customer's Cgpy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Chad:
Relief Valve.
Air Inlet
Check Valve
Initial Test
Aoi�
DC- Closed 27
Tight .�
Closed Tight
Lcalccd ❑
Opened at
osid
Opened at
_psid
� d
- - 13,
RP-_,_ nsid
Leaked p
Did not Open p
Leaked p
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
'right p
Closed Tight p
Opened at
'--WW
Opened at
vsid
� d
RP
The above is certified to be true.
Firm Name (1Y ►�� Vr4zclpf1 Catified Tester
Firm Address N I- n iThQn (, Cat. Tester No Date ,S
64 P� I _�-, 0 N I.
Gauge # 0Q0 I
Date last accuracy tested J2 �� 3
White - Customer's Cgpy Yellow - City Copy Pink - Tester's Copy