2013_1011 (10)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: // // t^q
The backflow prevention assembly detailed below has been tested and mamutmed as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve 0 Atmosphere Vacuum Breaker
�v
Manufacturer A ja&,C� Size
Model Number /f? �° dcz�A, Located At
Seriai Number 4k
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
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REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ReW Valve
Air Inlet
Check Valve
1st Check it .
tad Check I
Initial Test
DC- Closed
Closed Tight
id
Opened at
Opened at
, . id
Tight
Leaked
0
sid
_� d
RP -_psid
Leaked o
Did not Open D
Leaked 0
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight
0 Opened at
Opened at paid
Repair Tight o
osid
_osid
RP
The above is cesi fled to be true.
Firm Name
Cardfied Termer �
/
rt O-t eor��
Firm Address p p 9 PV- 7
CaL Tester No. SPD-&o IS-7 Date 13
1�J -)S,. '7Slh'
Gauge # d-7,0'9 A 4 ,?9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
a