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2013_0906CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: 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 n Manufacturer Model Number Reduced Pressure Principle Double Check Valve p % Serial Number ggz TYPE OF ASSEMBLY C Pressure Vacuum Breaker r Atmosphere Vacuum Breaker Size Located At a r �', The above is certified to be true. Firm Name mac. f xv L O I-nm Certified Tester -� c Y Y� S C her � Firm Address ,0DJ� /26 74r-a.aj UL11h Cert. Tester No. 9111(V�W i Date 2Z(L 7x -2G0SI� Gauge # ' Date last accuracy tested /©1ph /,2- 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 oSid Tight, ❑ RP- Psid Leaked ❑ Leaked ❑ , osid oSid Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at oSid Repair Tight ❑ psid oSid RP sid The above is certified to be true. Firm Name mac. f xv L O I-nm Certified Tester -� c Y Y� S C her � Firm Address ,0DJ� /26 74r-a.aj UL11h Cert. Tester No. 9111(V�W i Date 2Z(L 7x -2G0SI� Gauge # ' Date last accuracy tested /©1ph /,2- White - Customer's Copy Yellow - City Copy Pink - Tester's Copy