2013_0104 (11)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAIviE OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: (Q it K S. L It 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.
C Reduced Pressure Principle
❑ Double Check Valve
Manufacturer (.kc fll )
Model Number L F0y (, 0 1
Serial Number Co a 3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size /L-,
Located At Ayiu c l� A k
The above is certified to be true.
Firm Name Al ke d -1 ; • O F'rd g ej .'
Firm Address c'l--y c ? n'1,- , /- J4 # 30U
Gauge # C)c jo.)V Ss tp
Date last accuracy tested 3Z V2 0u
Certified Tester 7,,c M . /-
Cert. Tests No. KPcv -0 S 7 S Date 11L-J,1, 03
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
Tight ❑
Closed Tight in
Leaked ❑
Opened at
osid
Opened at
I ,psid
psid
RP -_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 Al ke d -1 ; • O F'rd g ej .'
Firm Address c'l--y c ? n'1,- , /- J4 # 30U
Gauge # C)c jo.)V Ss tp
Date last accuracy tested 3Z V2 0u
Certified Tester 7,,c M . /-
Cert. Tests No. KPcv -0 S 7 S Date 11L-J,1, 03
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy