2013_0919CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAIN'T'ENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: LS f- -MIC A 22dAA i vA
The back low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C� Reduced Pressure Principle a Pressure Vacuum Breaker
i� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer INIAS Size 91
Model Number 0 G-1 M Located At to
Serial Number _
The above is certified to be true.
Firm Name Q A iL L) ti %€'� Certified Tester Adzu-n e- &
Firm Ad&=00 00K 0 L(A�J �] Cert. Testa No. Hnnefl tc, Date iqTe
Gauge # .3-j
-�
Date last accuracy tested 10L 4 —�
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 2r
Opened at
Opened at
nsid
Tieht ❑
Leaked ❑
usid
nsid
RP- ._psid
Leaked
Did not Open o
Leaked ❑
airs
f e %'We&
and
Materials
Used
����
i o� puxd5
Test After
DC- Closed
Closed Tight
Opened at
Opened at
nSid
Repair
Tight 1AK
RP Lsid
1 ' T
psid
csid
The above is certified to be true.
Firm Name Q A iL L) ti %€'� Certified Tester Adzu-n e- &
Firm Ad&=00 00K 0 L(A�J �] Cert. Testa No. Hnnefl tc, Date iqTe
Gauge # .3-j
-�
Date last accuracy tested 10L 4 —�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy