2013_0220 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE 11
BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL I
LOCATION OF SERVICE: 150 I r 8at IA/IL & 40,t( % 7fD1 °)
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
c Reduced Pressure Principle 12 Pressure Vacuum Breaker
VDouble Check Valve a Atmosphere Vacuum Breaker
Manufacturer
Size $ r r
Model Number X Located At l u E �L%f �-t -
Serial Number 100M.
The above is certified to be true.
Firm Name , & f-t ct 't eSIlC � M"7 Certified Tester ov 42;
Firm Addr= &—J o. 715 d • �!l t�rl 11�y� Cert. Testa No. Date ? -,26
-t�r-19
Gauge # {+ i TM V 73/77
Date last accuracy tested lag. 3, f,)-
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
osid
Tight
Leaked Cl
psid
oSid
RP- t. L DSid
t •�
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
------- psid
Repair
Tight C3
psid
trSid
RP sia
The above is certified to be true.
Firm Name , & f-t ct 't eSIlC � M"7 Certified Tester ov 42;
Firm Addr= &—J o. 715 d • �!l t�rl 11�y� Cert. Testa No. Date ? -,26
-t�r-19
Gauge # {+ i TM V 73/77
Date last accuracy tested lag. 3, f,)-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy