2013_0104 (6)CHECK ONE:
IRRIGATION
DOMESTIC_'
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1075 -4,. R., M- -r- #1 3m)
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve c Atmosphere Vacuum Breaker
3/L4 Manufacturer I .�`?�L Size n n
Model Number fyX Mzl Q7 Located At A�c� P— Py _ (ce �.
Serial Number :kLn7UL-
The above is certified to be true.
Firm Name Ale(i prr,feclsv�
Firm Address
Gauge # _C)C, ! L) aO L� 1,
Date last accuracy tested 3/10 Qu i
Certified Tester C, 5 /0 . &-LA �
CerL Testa No. -2S- Date I ^
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked Cl
Sid
Q, Ll psid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name Ale(i prr,feclsv�
Firm Address
Gauge # _C)C, ! L) aO L� 1,
Date last accuracy tested 3/10 Qu i
Certified Tester C, 5 /0 . &-LA �
CerL Testa No. -2S- Date I ^
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy