2013_1218 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /VtCL
9
70P Al. Dn-lo,, -TaIO )ed
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
Double Check Valve
Manufacturer &� A415
Model Number t2n:2 M
Serial Number C71IDD/ O5
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
[7 Atmosphere Vacuum Breaker
qq „
Size � / /I `
Located At Ulf I/ T — 16 &- 'c °t -
The above is certified to be true.
Firm Name l z/ / ;,5 T Certified Tester
Firm Address Z- MP 4. T,l' j('12-4iert. Tester No. / Date
Gauge # -a f p 1 _
Date last accuracy tested % —129 —/, 3
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
�j
DC- Closed
Tight
RP - %� osid
Closed Tight )C
Leaked C3
/
Opened at
nsid
Opened at
oSid
oSid
Lccaed ❑
Did not Open O
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight ❑
psid
oSid
RP Sid
The above is certified to be true.
Firm Name l z/ / ;,5 T Certified Tester
Firm Address Z- MP 4. T,l' j('12-4iert. Tester No. / Date
Gauge # -a f p 1 _
Date last accuracy tested % —129 —/, 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy