2013_0104 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: '.), c k 1,; n k ; 3t kc,,,<, I075 S. `e If L SE 03C C)
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 ❑ Atmosphere Vacuum Breaker
Manufacturer t,,A,�A- Size
- LI
Model Number LFCV e PL Q r
Serial Number 001 l9O
Located At kue2 is
The above is certified to be true.
Firm Name AlLcrIJE-,L f- ci,011
Firm Addres'�� f r ; GI
G It..,CJ , T X
75001
Gauge # OGI I C -,-
Date last accuracy tested 34 "-xl ,�
Certified Testa 37,,e �, A. / .
Cert. Testa No. P,P(m; la S7 S Date / avi3
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
Tight ❑
Leaked ❑
nsid
'-I• Ll sid
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 AlLcrIJE-,L f- ci,011
Firm Addres'�� f r ; GI
G It..,CJ , T X
75001
Gauge # OGI I C -,-
Date last accuracy tested 34 "-xl ,�
Certified Testa 37,,e �, A. / .
Cert. Testa No. P,P(m; la S7 S Date / avi3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy