2013_0220 (5)CIIECK ONE:
IRRIGATION FIRELINE
BACKILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 160 1 P, . &H -Ltr t IU • (10021L 1 Tk 75b
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
IV Double Check Valve a Atmospheric Vacuum Breaker
Manufacturer Wdtf5 Size 07 r r
Model Number p d I Located At &invfh 5o e, of a_o f�aftik
Serial Number ?q 0
The above is certified to be true.
Firm Name jA hi f i Domea Certified Tester
Firm Addrm P.O. 6DXT9h a W U -rt Cert. Tester No. W 7041, 1, Date a "a74
-7(p r7q
Gauge # waltS TOM to l-M
Date last accuracy tested, =�-
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
T_,bb5
Tight
RP-_L- psid
Leaked ❑
1,
Dsid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight 13
nsid
nsid
RP Sid-
The above is certified to be true.
Firm Name jA hi f i Domea Certified Tester
Firm Addrm P.O. 6DXT9h a W U -rt Cert. Tester No. W 7041, 1, Date a "a74
-7(p r7q
Gauge # waltS TOM to l-M
Date last accuracy tested, =�-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy