2013_0812CHECK ONE:
IRRIGATION DOMESTIC FiRELINE t/
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
'N6 1914
The baddiow prevention assembly detailW below has been tested and mamumad as required by TNRCC
regulations and is catified to be operating within acceptable parameters.
C Reduced Pressure Principle
Double Check Valve
Mannfactum
Model Number
SerialNumbcr
TYPE OF ASSEMBLY
• Pressure Vacm Breaker
• Atmospberc Vacru rn Breaker
size` t�
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doable Check Valve Assembly
1st Check 2, Check S. Relief Valve Air Inlet Check Valve
Initial Test DC- Closed lased Tight 2r Opened at Opened at n sid
Tight Leaked ❑ asid _psid
L ❑ Did not Open ❑ Leaked ❑
Repairs
and
Materials
used
Test ABer DC- Closed Closed Tight ❑ Opened at Opened at
Repair Tight ❑ osid nsid
RP
The above is certified to be true.
Firm Name ACtio-- -Lae- Certified Tester /Cep e alr�
Firm Ad d' lt�o 13&4- ` - "7 9i? Cut Tesmr Date
Gauge # O ?D9d-4.S'S
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy