2013_0916CHECK ONE:
IRRIGATION_
*14M
FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # _
alife
LOCATION OF E15VICE:
D��� T
�ol9
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
e , Reduced Pressure Principle a Pressure Vacuum Breaker
/ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer f--e C Size
Model Number , b � Located At} 4.,V ax, I `��'��� �' � �-� ro ef\ d�
Serial Number3
The above is certified to be true.
Firm Name s -r- `� Certified Testa bXQ' Q'
Firm Address 41:5 ow URs Or Cert. Testa NoR QC0g51'-f Date9_ 1 &` -13
6630
Gauge
Date last accuracy tested a-1
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 6-13,
DC -Cl ed
Tight 0 W
RP -_psid
Leaked ❑
/Closed Tight
Leaked ❑
Opened at
asid
Opened at
osid
Did not Open o
osid
Leaked ❑
Reps
and
Materials
o _"
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name s -r- `� Certified Testa bXQ' Q'
Firm Address 41:5 ow URs Or Cert. Testa NoR QC0g51'-f Date9_ 1 &` -13
6630
Gauge
Date last accuracy tested a-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy