2013_1011 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACCFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ///0 f,- 4 �
The backflow preveation assembly detailed below has beea tested and maintained as required by TNRCC
regulatiams and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacawm Breaker
i,,e Double Check Valve ❑ Atmosphere Vacuum Breaker
L V� r.
Manufacturer 9 n
Model Number / Located At S' S .�'"`°�
Serial Number // S & 61
White - Customer s Copy Yellow - City Copy Fink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check -
2nd Cheri: Z •
Initial Test
DC- Closed
Tight
Closed Tight L.e'
Leaked O
Opted at
�gsid
Opened at
----_-p id
-- sid
RP- __--„psid
Leaked o
Did not Open o
Leaked O
L
DC- Closed
Closed Tight O
Opened at
Opened at
maid
Tight O
--jy; id
sid
RP
The above is certified to be, true.
f�
Firm Name . - t'r T1 cemf d Tester Xe n ✓t a -tL
Firm Adds+ u Po 8 4-- 79'7 Cert. Tester No. MaOo b IF7 Date
pJ-, ) -) ry- -7sr�
Gauge # d76 ga 4 d'$
Date last accuracy tested d;+ / %' 3
White - Customer s Copy Yellow - City Copy Fink - Tester's Copy