2013_0426 (8)CIIECK ONE:
IRRIGATION _K
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: _ 1-6)0 l- �t+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.
TYPE OF ASSEMBLY
❑ Reduced Pressure PrmCiDle ❑ Pressure Vacuum Breaker
tO Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �C -r—, 5 Size
Model Number Q 0'2 P "I _ I
Serial Number A J I I. 3C)
J
Located At Al e -T cr & `> - C--'7-
The above is certified to be true. Ye-5
Firm Name �j
Firm Address i rJ rh"' ,�, I /
Gauge # C f1LE,',�,) / kS'
Date last accuracy tested �V/3
Certified Tester
Cent. Tester No. L'V 6 1- 0 Date Ell ti�3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight k
Opened at
Opened at
esid
Tight 1.6 9
RP- __,esid
Leaked L ❑
osid
esid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_esid
Repair
Tight ❑
nsid
esid
RP Sid
The above is certified to be true. Ye-5
Firm Name �j
Firm Address i rJ rh"' ,�, I /
Gauge # C f1LE,',�,) / kS'
Date last accuracy tested �V/3
Certified Tester
Cent. Tester No. L'V 6 1- 0 Date Ell ti�3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy