2013_0104 (5)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,., ; r . k Z!7 -4 ,;—Y?C>
The bacifflow 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
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer L, A---, Size 3/LI
Model Number L Fb0S PL a T Located At "r' �:
Ili
Serial Number Ooa3f5
The above is certified to be true.
Firm Name Af l:xd L �
Firm Address
&C., T
Gauge # acl it ), hl �
Date last accuracy tested �/ l��c
Certified Tester J ,-f--> /" - i n
Cert. Tester No. &P6c IJS7S Date L/ -�(,'13
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 ❑
osid
1. C.- psid
R.P -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name Af l:xd L �
Firm Address
&C., T
Gauge # acl it ), hl �
Date last accuracy tested �/ l��c
Certified Tester J ,-f--> /" - i n
Cert. Tester No. &P6c IJS7S Date L/ -�(,'13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy