2014_0523CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
uiiL5
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
xDouble
Reduced Pressure Principle
Check Valve
Manufacturer
Double Check Valve Assembly
Model Number��
Serial Number
1st Check
2nd Check
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
�t/
Size ,��,�,,�
Located At �' ° ' "" ld'ri� d
The above is certified to be true.
Firm Name � Certified Tester 9
ev
Firm Address Pd 6 d k Z i 01 I �' Cert. Tester No. 1 Z7 Date -7-3 -1
M wr.cl t-R -7 9-d27
Gauge # 03a j 0 q i?-
Date last accuracy tested q—/5 l
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
Tight
lZ -;?10 DSid
Closed Tight
Leaked ❑
Opened at
vSid
Opened at
nSid
Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
Dsid
Opened at
DSid
_______psi d
RP sid
The above is certified to be true.
Firm Name � Certified Tester 9
ev
Firm Address Pd 6 d k Z i 01 I �' Cert. Tester No. 1 Z7 Date -7-3 -1
M wr.cl t-R -7 9-d27
Gauge # 03a j 0 q i?-
Date last accuracy tested q—/5 l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy