2013_0812 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FiRELINE y
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REM)RT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Ratuced Pressure Principle
Ler- Double Check Valve
Manufacturer
Model Number 5 y
Serial Number
TYPE OF ASSEMBLY
e Pressure Vactnmr Breaker
fl Atmosphere Vacuum Breaker
size 3i C�-
Located At mz 5, ' �.
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Doable Check Valve Assembly
Ist Cheek i 2nd Check J, ,F Relief Valve Air Inlet Check Valve
Initial Test DC- Closed -Closed Tight -6 Opened at Opened at nsid
Tight Leaked Ci `—ps id —I id
L ® Did riot Open o Leaked
Repairs
and
Materials
Used
The above is certified to be true.
F= Name
Firm Ad&vss,-94,2-'T lPo i3o`k 2 9'?
Gauge # 0Z E'q 0.4 9'8
Date last accuracy tested 6-1)-)!>
Cat fwd Testa
Cat. Testa Nod Pez,° 615-1 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
Fol'