2013_0426 (6)CIIECK ONE:
IRRIGATION
DOMESTIC
f ,,j (4 ti
FIRELINE )i
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: L°100 () i %) i d e -i d
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
�i
Manufacturer
Reduced Pressure Principle
Double Check Valve
blic � --t-5
Model Number
Serial Number
TYPE OF ASSEMBLY
1: Pressure Vacuum Breaker
17 Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true. Ye 5
Firm Name Al, �� �' ,J i - ,C-
Firm Address PC) GO A 7 '71-
�,,'c x c. Vn e, G %, t z
Gauge #
Date last accuracy tested 3//3
Certified Tester NA)C,-4V1,e--alt° �►v► Imo'
Cent. Tester No. cl `0 3� Date
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
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight I. tv Z
Leaked `�' ❑
osid
nsid
RP -_psid
Leaked Cl
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Altar
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true. Ye 5
Firm Name Al, �� �' ,J i - ,C-
Firm Address PC) GO A 7 '71-
�,,'c x c. Vn e, G %, t z
Gauge #
Date last accuracy tested 3//3
Certified Tester NA)C,-4V1,e--alt° �►v► Imo'
Cent. Tester No. cl `0 3� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy