2013_0426 (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: go(:) bjjj6,.(3
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
C Reduced Pressure Principle C Pressure Vacuum Breaker
;0 Double Check Valve C Atmosphere Vacuum Breaker
x [)t nA
Manufacturer WC= t �r � Size
Model Number --Z'2 "I U 14 Located At ti10 �Tv-, �l
Serial Number 10D,91 .5 11 Q 47
The above is certified to be true.
Firm Name AL .r cci ) (-i -e
Firm Address PQ 641K ')% 7
jvo ;Kc V% e' C Z7 + c
Gauge # L' ?,� 6,_6 jr) I
Date Last accuracy tested 3//-3
Certified Testa - 00- -i.e W e yr A f,'
Cat. Tester No. 0CX r -1 J S- Date f dlc we
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 Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ,3,3 k P
Closed Tight 0
Leaked . At
Opened at
DSid
Opened at
nSid
nSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nSid
nSid
RP sid
The above is certified to be true.
Firm Name AL .r cci ) (-i -e
Firm Address PQ 641K ')% 7
jvo ;Kc V% e' C Z7 + c
Gauge # L' ?,� 6,_6 jr) I
Date Last accuracy tested 3//-3
Certified Testa - 00- -i.e W e yr A f,'
Cat. Tester No. 0CX r -1 J S- Date f dlc we
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy