2013_0905 (12)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:: ``d? drf 1i r,l a e�i1 y .% �U✓/r�C'�? .�5%J /
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
Model Number ) U o C 6
Serial Number r) / 5 A
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphcre Vacuum Breaker
Size
Located At K, fe Y Yo o,m
The above is certified to be true.
Firm Name �' / rc , (�i zi i /y_J
Firm Address PQa )(A 7lrY -) e
T� 76v94
Gauge # g(} f/ a g5` -
Date last accuracy tested ll l (' A'),
Certified Tester J C' r Y TC
Cent. Tester No. &i,DCC96 F 5 Date l/
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
nsid
Tight E'
Leaked ❑
nsid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name �' / rc , (�i zi i /y_J
Firm Address PQa )(A 7lrY -) e
T� 76v94
Gauge # g(} f/ a g5` -
Date last accuracy tested ll l (' A'),
Certified Tester J C' r Y TC
Cent. Tester No. &i,DCC96 F 5 Date l/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy