2013_1218CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
700 N, ,01-n-f o n a P lC4
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
Y Double Check Valve
Manufacturer Fe- bel
Model Number ig5o
Serial Number A109(.0
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
4: If
Size
Located At
por gy M,P eusl'.S
b4 G% o -U- of 1, -r-
The above is certified to be true.
Firm Name 411 rz!,,4— Certified Tester Ty r taw-
Firm Address i U)o4 , TX -7 &ZAjVCert. Tester Noh—f% 7'(y Date .12-19"-13
Gauge # 0&071-79-41
Date last accuracy tested -7 - /a- /,,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAIC R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
P'L�,5
DC- Closed
Tight
RP -sid
Leaked ❑
Closed Tight
Leaked C3
Opened at
Dsid
Opened at
_nsid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_psi d
Repair
Tight ❑
psid
osid
RP sin
The above is certified to be true.
Firm Name 411 rz!,,4— Certified Tester Ty r taw-
Firm Address i U)o4 , TX -7 &ZAjVCert. Tester Noh—f% 7'(y Date .12-19"-13
Gauge # 0&071-79-41
Date last accuracy tested -7 - /a- /,,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy