2013_1120 (6)CHECK ONE:
IRRIGATION
DOMESTIC FIR.ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Goo En y.- ODd"'
The backfiow 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
�K Double Check Valve
Manufacturer wa
Model Number _Z7 L) 0 (-h
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
�i
Size
Located At `SW rite. Wut 14-
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
P� Double Check Valve Assembly
1st Check 2nd Check: Relief Valve Air Inket Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at iesid
Tight 2. & Leaked Z o nsid ,_----psid
RP• ..... psid
Leaked ❑ Did not Open D Leaked C
Repairs
and
Materials
Used
Test After I DC-Closed I Closed Tight C I Opened at I Opened at I _,__nsid
Repair Tight ❑ _,. nsid _,esid
The above is catified to be true.
Firm Name *-- e A rP_ P�05
Firm Address & 7
Gauge #M I 1 QQ 75
Date last accuracy tested J-
Certified Testa J %6d 57t�
CatTestallo.5PW-/0651 Date 2,0113
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy