2013_0220 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Ir')n I E i�p,L� L&u Co ,-7)c 2na
The bacldlow 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
❑ Reduced Pressure Principle 12 Pressure Vacuum Breaker
VDouble Check Valve C Atmosphere Vacuum Breaker
Manufacturer - UrVSC.L1 Size
Model Number YU C." Located At 41 W IIAL -CF fs
Serial Number (�1033°I
The above is certified to be true.
Firm Name l AV(- 4 YYI M, C 3 9
Firm Address PO �5�ts 1�4✓`f7!t �%
.�1,
Gauge # Yj�( 1 t�Q°i � 073 8
Date last accuracy tested 1)-'3- (, —
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
Tight
Leaked ❑
nsid
nsid
RP- (a sid
1,y
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
teri
Ma aIs
v (v;
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight C3
nsid
nsid
RP sid
The above is certified to be true.
Firm Name l AV(- 4 YYI M, C 3 9
Firm Address PO �5�ts 1�4✓`f7!t �%
.�1,
Gauge # Yj�( 1 t�Q°i � 073 8
Date last accuracy tested 1)-'3- (, —
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy