2013_0906 (25)CHECK ONE: `
IRRIGATION DOMESTIC FIRELINE /
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 14 L4 C u hr. Z1i Z
The baclflow 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 12 Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer 5 Size
Model Number 24ce U 15
Serial Number (_, - % 5 4` Z
Located At ,rj-
The above is certified to be true.
Firm Name
l Certified Testa t
r„ /j
F
Firm Addressl (�, CYO - I / .n Cat. Testa No. Date
Gauge # 171 C'-
Date last accuracy tested `
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 in
RP- �-psid
Leaked ❑
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
, i
The above is certified to be true.
Firm Name
l Certified Testa t
r„ /j
F
Firm Addressl (�, CYO - I / .n Cat. Testa No. Date
Gauge # 171 C'-
Date last accuracy tested `
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy