2013_0220CHECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL \
LOCATION OF SERVICE: j � � t E, �P 4- 1 , f-,e J�A C}
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.
TYPE OF ASSEMBLY
V Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer Ller e- Size 6 (t r
Model Number DWI I � Located At � W ya u l� i't 1'L Lt Q-
Serial Number
The above is certified to be true.
Firm Name Jig' Ftrt✓+ 61'V1CS'fitS1I�1(� Certified Tester
Firm Address i A • OK 7C6 /R a �VA Cert. Tester No. Date ��13
lic'm1y
Gauge # " j q� q _27�/76
Date last accuracy tested J_). - 3 , I
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
Opened at
Opened at
nsid
YW6
Tight
RP- Dsid
Leaked ❑
i
vsid
nSid
Leaked Cl
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
asid
nsid
RP sid
The above is certified to be true.
Firm Name Jig' Ftrt✓+ 61'V1CS'fitS1I�1(� Certified Tester
Firm Address i A • OK 7C6 /R a �VA Cert. Tester No. Date ��13
lic'm1y
Gauge # " j q� q _27�/76
Date last accuracy tested J_). - 3 , I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy