2013_0522 (5)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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer LA
Model Number 6051 W
Serial Number )--] 34 3 �0
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
G Atmosphere Vacuum Breaker
Size
Located At
nnU1 -F r����..e✓
The above is certified to be true.
Firm Name 1 (if l Certified Tester r' Yarn( "R + C_ i e
Firm Address ni( 1 5 (0dQK 4' Cent. Testa No. 5f 125q 3 Date 3
Gauge # -��
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 c 6-
Opened at
Opened at
osid
Tight ❑
RP- "I -'3'psid
Leaked ❑
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 1 (if l Certified Tester r' Yarn( "R + C_ i e
Firm Address ni( 1 5 (0dQK 4' Cent. Testa No. 5f 125q 3 Date 3
Gauge # -��
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy