2013_0905 (18)CIIECK ONE:
IRRIGATION
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DOMESTIC
FIRELINE jz/
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: n i, i, t%, c Zesie LZo IV, C ,),), ? %1*d 2
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 /� "a 5 Size
Model Number
?( j Located At ,YJ SC'. Y 1rG�'le A';
Serial Number - �E S
The above is certified to be true.
Firm Name ro 6e,0,4 t
Firm Address /? 1106 7
r, 26 el r
Gauge #
Date Last accuracy tested
Certified Testa
CerL Testa No. NloeGC$"��9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked ❑
psid
oSid
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name ro 6e,0,4 t
Firm Address /? 1106 7
r, 26 el r
Gauge #
Date Last accuracy tested
Certified Testa
CerL Testa No. NloeGC$"��9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy