2013_0426 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 4/06
t 'U' t C( e-,,x C1
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
r- Reduced Pressure Prmcivle C Pressure Vacuum Breaker
V Double Check Valve fsc 1 � ❑ Atmosphere Vacuum Breaker
Manufacturer Size f a�
Model Number '7 7 1 ��C 1 to Located At
Serial Number 100 0 4,'C, r / c;)oj '
The above is certified to be true. i e 5
Firm Name 46 rr,.'
Firm Address �0 � C"?
A)C;Kc, vvx -C vy t
Gauge # 0 OR.�r�
Date last accuracy tested 3/ 3
Certified Testa ( h��' �► +'► �'
Car. Testa No. L`ZY) i -/ J i' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ,Q
Opened at
Opened at
nSid
Tight d b
Leaked ❑
nsid
nSid
,jf
RP -_L
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
_nsid
Repair
Tight ❑
nSid
nSid
RP sid
The above is certified to be true. i e 5
Firm Name 46 rr,.'
Firm Address �0 � C"?
A)C;Kc, vvx -C vy t
Gauge # 0 OR.�r�
Date last accuracy tested 3/ 3
Certified Testa ( h��' �► +'► �'
Car. Testa No. L`ZY) i -/ J i' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy