2013_0905 (10)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: rk c� T/� e L c k �� /'j/, C �p� e /� r'' 1/9
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer
Model Number C`' CC
Serial Number 00C' " R 9 3r
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
/e
Size
1
Located At
The above is certified to be true.
Firm Name ��,�,U ('0/220
Firm Address 1.26 7 �rYulyiyyI
-7x ?�t,CS�
Gauge # ; L yC 75',0
Date last accuracy tested , /f) 1/U „2
Certified Testa �G ((U
Cei t. Testa No. 61 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
usid
Tight ❑
Dsid
Leaked ❑
nsid
usid
Leaked ❑
Did not Open ❑
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
psid
usid
RP sid
The above is certified to be true.
Firm Name ��,�,U ('0/220
Firm Address 1.26 7 �rYulyiyyI
-7x ?�t,CS�
Gauge # ; L yC 75',0
Date last accuracy tested , /f) 1/U „2
Certified Testa �G ((U
Cei t. Testa No. 61 9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy