2013_0104 (9)CHECK ONE:
IRRIGATION DOMESTIC t! FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1,i,k 1. -* (i! k,fc..i,r.,y 1075 S. & 14 1 ( t.3W
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
C. Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ,�A ,�. }��., Size 14) 1 1
Model Number L F k P _ G?T" Located At AL
Serial Number OAS %'
The above is certified to be true.
Firm Name Ail ;o d ; -o
Firm Address � (c3 NL_ef, #`3cy
Gauge # DPI 1(
Date last accuracy tested /I
i
Certified Testa �JT re % A
Cert. Testa No. 8ArV,) 5 -?�'- Date I I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAIaR
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
---psid
Tight ❑
Leaked ❑
psid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name Ail ;o d ; -o
Firm Address � (c3 NL_ef, #`3cy
Gauge # DPI 1(
Date last accuracy tested /I
i
Certified Testa �JT re % A
Cert. Testa No. 8ArV,) 5 -?�'- Date I I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy