2013_0830CHECK ONE:
IRRIGATION V
DOMESTIC
FIRELINE
BAGCFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
Il l' ✓'
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
Model Number �>
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
c
Atmosphere Vacuum Breaker
size / ,'
j !
Located At x.11 � L'1. -�" �U� �U�
The above is,/ccer certified to be true.
Firm Name r 11 �i� ,, OW Certified Te= yd � 6
Firm Address 1'1 ►- f I %,A Cent Testa No. 15141)ate �
Gauge # ib(oui , '2 4j
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 [Y'
Opened at
Opened at
oSid
I
Tight 11
RP- ✓'�� Dsid
Leaked ❑
- 1-
Dsid
oSid
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,/ccer certified to be true.
Firm Name r 11 �i� ,, OW Certified Te= yd � 6
Firm Address 1'1 ►- f I %,A Cent Testa No. 15141)ate �
Gauge # ib(oui , '2 4j
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy