2013_1011 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE ' 4"
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacldiow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable pa ametas.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure vacuum Breaker
p2- Double C //heck Valve ❑ Atmosphere Vacuum Breaker
Maaufacnaer fit/ size �f ,,'
Model Number 0`9Z AI I Located At
Serial Number z 8-Y b
White - Customer% Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 1. -q
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
— aid
Tight Ve
Leaked
_psid
� d
RP- _,psid
Leaked o
Did not Open O
Leaked ❑
Reps
e- le
and
%NS
Materials
Used
Test A8a
DC-Closed/4
Closed Tight vd
Opened at
Opened at
____-psid
Repair
Tight
d
psid
RP
The above is certified to be mm.
Firm Name A r?• •� N- f' Cereif ed Tester � ri 1P L
Firm Address Po 8 PV- % mss" r' Cat Testa No. 819ato 6 117 Date / 0 / 3
PJ--Xj -79y '7S lb ;?
Gauge # Q 7 6 90 4 d'9
Date last accuracy tested
White - Customer% Copy Yellow - City Copy Pink - Tester's Copy