2013_0104 (3)CHECK ONE:
IRRIGATION
DOMESTIC --,," FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Q, V,. T: h k a(- 1.,c -, I075 � . Py 14 1; C-
The back low 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
e Reduced Pressure Principle 12 Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Lk,, -t Size
Model Number �5yUM L} 0 T Located At
Serial Number r-f 7 s )--)9
The above is certified to be true.
Firm Name . A I I,- s r,( J- ; ..k
Firm Address P fl 0,300
Gauge # C19 (C -) U f C,
Date last accuracy tested 3/I� J
Certified rester
Cert Tester No. c- ,)5 7 Date 1 L o 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
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
nSid
Opened at
1. Q DSid
DSid
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
DSid
DSid
RP sid
The above is certified to be true.
Firm Name . A I I,- s r,( J- ; ..k
Firm Address P fl 0,300
Gauge # C19 (C -) U f C,
Date last accuracy tested 3/I� J
Certified rester
Cert Tester No. c- ,)5 7 Date 1 L o f,.,
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy