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2013_0612
CHECK ONE: IRRIGATION Peto, .� - � 3 25 7 DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: 111 C�QVI't\Cl Cf. 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. C / Reduced Pressure Principle Double Chxk Valve Manufacturer Model Number 0 Serial Number AA25 d6 7 TYPE OF ASSEMBLY C Pressure Vacuum Breaker D Atmosphere Vacuum Breaker Size '5�/rg t r Located At 5 dam ( �` cy4r� �`c The above is certified to be � true. Firm Name &v-, k- F(no_t- ! P e Certified Tester L Firm Ad k=gl3 bvstns Q(\� U00 ky, T�( Cat Testa No�09 d 5 ( Date Z -a -76036 Gauge # ©1, OS () q \,K 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 ist Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test L-/Z /3 DC- Closed Tight E 9 RP- psid Leaked C iClosed Tight Leaked o 121 Opened at nsid Opened at nsid Did not Open ❑ nsid Leaked ❑ Reps and Materials /i'0�u— Used Test After Repair DC- Closed Tight ❑ Closed Tight ❑ Opened at nsid Opened at nsid nsid RP sid The above is certified to be � true. Firm Name &v-, k- F(no_t- ! P e Certified Tester L Firm Ad k=gl3 bvstns Q(\� U00 ky, T�( Cat Testa No�09 d 5 ( Date Z -a -76036 Gauge # ©1, OS () q \,K Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy