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2013_0905 (13)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: !,h c r4 w A/ C6 402e 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 C Reduced Pressure Principle ❑ Pressure Vacuum Breaker ❑ Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer A-0 C I Size Model Number V U U /`3 Located At Serial Number The above is certified to be true. Firm Name //;% Firm Address 2, < Gauge # s© Date last accuracy tested IP //,- Certified Tester Cert. Tester No. � /' /r,�' �'l �,' 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 nsid Tight/ in Leaked ❑ nsid nsid 2 _ 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 //;% Firm Address 2, < Gauge # s© Date last accuracy tested IP //,- Certified Tester Cert. Tester No. � /' /r,�' �'l �,' 9 Date White - Customer's Copy Yellow - City Copy Pink - Tester's Copy