2013_1011 (7)CHECK ONE:
IRRIGATION
DOMESTIC V
FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: //// EX e 601 G",.e-,,
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuum Breaker
tz Double Check Valve o Atmosphere Vacuum Breaker
Maaufacuaer
l size
Model Number ®y? YYi t W Located At F -�_4.
Serial Number
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
9
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
gam{ Valve
Air Inlet
cuck Valve
let Check /, (o
2nd Check X
Initial Test
DC- Closed
Closed Tight le
Opened at
Opened at
.—ps id
Tight le
Leaked ❑
d
--josid
RP -_psid
Leaked o
Did not Open ❑
Leaked o
Repairs
and
Materiais
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
paid
Repair
Tight ❑
end
__p sid
RP
Ile above is certified to be true.
,Q f,,
Firm Name �, �' ►�� T Certified Test�.r i'�-e rt P-t , �'✓-
Firm Address Po 8 4- 7 9-/7 Cat Testes No. SP's 1 �7 Date
�J -79Y- '7Slh ii'
Gauge #k
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
9