2013_0129CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: S r (e p..r t`v,3
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer I-)`' #S
Model Number GQ2 vv) ?
Serial Number Zv2N y
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
3�
Size /
Located At uo,t - 0- Li, ���s
The above is certified to be true.
Firm Name Certified Tester _P
(zg4^j
y.5'�FSM r.���t rViu.J
Firm Address r-T, wT -QC. - 76oZ� -1 �i Cat. Tester No.l�ol35-q Date ��� • 1
Date last accuracy tested a - a /.,Q-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Wef Valve
Air Inlet
Check Valve
Initial Test
5
DC- Closed
Tight 2-2- e
RP- .__psid
Leaked C
osed Tight
Leaked 0
2-0
Opened at
psid
Opened at
osid
Did not Open o
nsid
Leaked
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
t,sid
Opened at
_____—.osid
_____p sid
RP sid
The above is certified to be true.
Firm Name Certified Tester _P
(zg4^j
y.5'�FSM r.���t rViu.J
Firm Address r-T, wT -QC. - 76oZ� -1 �i Cat. Tester No.l�ol35-q Date ��� • 1
Date last accuracy tested a - a /.,Q-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy