2013_0607CHECK ONE:
IRRIGATION DOMESTIC FIR.ELINE-
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 3,z—� m 1 Yl f a ,e-,,a
The backnow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e / Reduced Pressure Principle
� Double Check Valve
Manufacturer IA) b I K\ ns
Model Number
Serial Number��
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
size f) C
Located At CA a nA. Y 1
The above is cadfied to be true.
Firm Nam L Fk A� ► Sri
Firm Address ( C., _ a
15 Nen) Tj, 7 -�W9
Gauge # Dq- l.ot CJ3_3'_
Date last accuracy tested
Certified T
J i
Cent. Testa No. -P
-W—r )a Date
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
jS
DC- Closed
Tight - I z
--i
Leaked a
Closed Tight ;e
Leaked ,� ❑
Opened at
psid
Opened at
� d
Did not Open ❑
__.esid
Leaked ❑
Repairs
and
Materials
Used
Test Ai3er
Reps
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
� d
RP
common=
mommomms
The above is cadfied to be true.
Firm Nam L Fk A� ► Sri
Firm Address ( C., _ a
15 Nen) Tj, 7 -�W9
Gauge # Dq- l.ot CJ3_3'_
Date last accuracy tested
Certified T
J i
Cent. Testa No. -P
-W—r )a Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy