2013_0426 (10)CHECK ONE:
IRRIGATION ,0
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Yr'Ci ;� t .i • �"
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 ❑ Pressure Vacuum Breaker
3�% Double Check Valve 17 Atmosphere Vacuum Breaker
Manufacturer LU6° -1- -1. 5 Size j
Model Number 06 -7 s" l
Serial Number A s) 1, & 3 ._7
Located At t).1
The above is certified to be true. 7
Firm Name A L J ►fi-- v
Firm Address PC) Z; iX % (7 7l
Gauge # t: ?3 t.N 8
Date last accuracy tested -3 )1,.3
Certified Tester � (,JCS -t � �- W e v► � Or
Cert. Tester No. 000 7'1 � `i Date i-/ IJ01-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight f, b b
RP -„ Dsid
Closed Tight V
Leaked ❑
Opened at
asid
Opened at
nsid
Dsid
Leaked ❑
Did not Open ❑
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ Dsid
Repair
Tight ❑
Dsid
Dsid
RP sid
The above is certified to be true. 7
Firm Name A L J ►fi-- v
Firm Address PC) Z; iX % (7 7l
Gauge # t: ?3 t.N 8
Date last accuracy tested -3 )1,.3
Certified Tester � (,JCS -t � �- W e v► � Or
Cert. Tester No. 000 7'1 � `i Date i-/ IJ01-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy