2013_0522 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW 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.
❑
Reduced Pressure Principle
❑
Double Check
Manufacturer
}.Valve
W " (-A
Model Numbery
- 1�
Serial Number
J4 oo r,
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 1J<
Located At Y1
The above is certified to be true.
i r j
Firm Name �' Certified Testa
Firm Address') f) 1 `5 ft&,' "Ak )�d Cat Testa No. 2 59 ? Date
Gauge # C/qm n
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
osid
Tight ❑
Leaked ❑
i o sid
osid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
i r j
Firm Name �' Certified Testa
Firm Address') f) 1 `5 ft&,' "Ak )�d Cat Testa No. 2 59 ? Date
Gauge # C/qm n
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy