2013_1218 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACK{FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: AA OLT « -ems -?F
7D o AA 0e.-i-A0 el
The back-flow prevention assembly detailed below has b
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
5t,o
maintained as required by TNRCC
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manu W facturer CL 45 Size 1 f
Model Number 75 7 Located At ya tc 84Ck fn Ire
Serial Number r A - / / -7-T
The above is certified two be true.
Firm Name A11 / Certified Tester Ty I i° � " Gt1%la %� r�
Firm At1dres a,ulrW, Tx- 014cit Tester No. a Pool q7 F10 Date 12-19-13
Gauge #
Date last accuracy tested -7-10-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF KER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
gS
DC- Closed
Tight �
RP -osid
Leaked ❑
Closed Tight '§X
Leaked ❑
°? 8
Opened at
sid
n,
Opened at
oSid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight 11
nsid
osid
RP Sid
The above is certified two be true.
Firm Name A11 / Certified Tester Ty I i° � " Gt1%la %� r�
Firm At1dres a,ulrW, Tx- 014cit Tester No. a Pool q7 F10 Date 12-19-13
Gauge #
Date last accuracy tested -7-10-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy