2013_0506 (2)CHECK ONE:
Vi'At1, Ry; lyd
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
°C
LOCATION OF SERVICE: qc)c) Nui8rq�
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 C Pressure Vacuum Breaker
V Double Check Valve J�sC nA C Atmosphere Vacuum Breaker
Manufacturer we , T ry Size 13
Model Number i 7yr L Located At A'L)
Serial Number 10( j 1 3 f 1 02
The above is certified to be true.
Firm Nam At: T t J r, .-<
Firm Address Pr) &J A 7 9')
('0C K NC c"'. --
Date last accuracy tested %3
Certified Tester LWc-t-it- 0 eg,n LA -P'
Cert. Tester No. i14C'`i h— Date 'b 0611
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
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Tight 3<-, I'
Leaked
vsid
vsid
RP- ._psid
Leaked C
Did not Open o
Leaked ❑
Repairs
c�
and
Materials
Used
Test After
DC- Closed
Closed Tight V
Opened at
Opened at
vsid
Repair
Tight 3,0 0
RP sid
v'
sid
osid
The above is certified to be true.
Firm Nam At: T t J r, .-<
Firm Address Pr) &J A 7 9')
('0C K NC c"'. --
Date last accuracy tested %3
Certified Tester LWc-t-it- 0 eg,n LA -P'
Cert. Tester No. i14C'`i h— Date 'b 0611
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy