2013_1011 (8)CHECK ONE:
IRRIGATION ✓ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: z
The backflow 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
C Reduced Pressure Principle C Pressure V== Breaker
,Z" Double C beck Valve ❑ Atmosphere Vacuam Breaker
% it
Manufaczsaer
W a-� Size Z'
Model Number en' r% n''r Located At F-X--4 4 S/aek
Serial Nuniber f S
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Re id Valve
Air Inlet
Check Valve
1st Check l , Cv
2nd Check 2 • v
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
— id
Tight
Leaked o
nsid
� d
RP -_teid
Lea W- o
Did not Open o
Leaked O
Repairs
LUsedl
DC- Closed
Closed T ight o
Opened at
Opened at
psid
Tight
raid
__—__-
osid
RP
The above is certified to be ttroue.
l
Firm Name d t t x>— )!L Catified Tester ✓t 1 "l
Firm Address Pd PV- 7-9% Cart. Testa No. SPvft IS-7 Date
Gauge # o°76,9a 4 99
Date last accuracy tested 1.3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy