2013_0905 (11)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ;2n 7-)c /%/, 'Conic //4 / �t
The bacldlow 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 ❑ Atmosphere Vacuum Breaker
Manufacturer X9112 S Size .-11
Model Number ., � CC O %J
Serial Number '2600 A m/2,
Located At b i'Se r
The above is certified to be true.
Firm Name a t ro� t77ts'
Firm Address W A C�
,_ ?Gem
Gauge #
Date last accuracy tested
Certified Tester /
Cert. Tester No.,'?t °f' a a Z 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 ❑
'� ' y
Did not Open ❑
Leaked ❑
Repairs
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 a t ro� t77ts'
Firm Address W A C�
,_ ?Gem
Gauge #
Date last accuracy tested
Certified Tester /
Cert. Tester No.,'?t °f' a a Z Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy