2013_0812 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backilow prevcatiaa assembly Mailed below has been tested and mamamed as required by TNRCC
re_$ulations and is certified to be operating within acceptable parameters.
e Reduced Pressure Principle
Double°° Check Valve
Manufacnaer T --�
Model Number yo
Serial Number -7- 3 n �
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size _
Located At - V
REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check I - q- 2nd Check Rew Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at __ps id
Tight Leaked ❑ psid `)sid
Leak-ad p Did not Open o Leaked ❑
Reps
and
Materials
Used
The above is certified to be true.
Firm Name
Firm Addresses Ec , t Z '7 5'7 Cart. Taster Nola A:;�P° 615` 7 Date 13
Pla* -r*. -7t re- 8
Gauge # 07L'4 4 S$
Date last accuracy tested
White - Customers Copy Yenow - City Copy Pink - Tester's Copy