2013_0104 (10)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIG'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: << k:1,,
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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number L f7UU ` L o I - Located At tx_,� 5
Serial Number -� 0 1 U (s k
The above is certified to be true.
Firm Name k , d --;, p_ prL -C L (;. Certified Testa . M . l:,Lt .
Firm Address Pl, J, ; ti #i 3 _ Cert. Testa No. Date X13
Gauge # (jet l()QU h Cc
Date last accuracy tested ,/)c,l --:�_
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
t-1 • d psid
Tight ❑
Leaked ❑
psid
i • Lo psid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm Name k , d --;, p_ prL -C L (;. Certified Testa . M . l:,Lt .
Firm Address Pl, J, ; ti #i 3 _ Cert. Testa No. Date X13
Gauge # (jet l()QU h Cc
Date last accuracy tested ,/)c,l --:�_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy