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2013_1120 (2)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: (0 DO The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. C Reduced Pressure Principle Double Check Valve Manufa=rer W-4- s Model Number 001M1 Serial Number PpS, i Initial Test Repairs and Materials Used TYPE OF ASSEMBLY C Pressure Vacuum Breaker C Atmosphere Vacuum Breaker Size 0/0 Located At SW Fire Vau REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly i 1st Check 2nd Check Relief Valve Air Inlet Check Valve DC- Closed Closed Tight )d, Opened at Opened at ---p sid Tight 2.O Leaked o vsid --_—_.psid RP- _,._.psid Leaked © Did not Open C Leaked C Test After DC- Closed Repair Tight RP Closed Tight o 1 Opened at I Opened at I . _nSid O nsid sid The above is certified to be true. Firm Name k- o rine, S Firm Address -7 ��q cue -77� Gauge # 0&//00 Date last accuracy tested 26L3 Certified Tester L" ii IkS7'0 tie Cent. Tester No. &bQtO6o 5) Date lk S6 3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy