2013_0822 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE. L/
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1-6005, A FrP2 p o r t 2A1,1 y
The back-flow prevention assembly detailed below has been tested and maintained as requited by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer lLtfS Size .4 (•
Model Number -757 D C%%!4 °GU Located At Uoele, 4-j gi iZ11,2a /4 — iePGe Adt n
Serial Number T X 26 '/ 3
The above is certified to be true.
Firm Name Am eric as Af fd . S/!r i a- k1e P Certified Tester
Firm Address 60 v S Q,- ,Cc S& Cert. Tester No. Ef" -b /gf Date �=
Gauge # e7619/7S2-
Date last accuracy tested /Z -(Z. —12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight K
Opened at
Opened at
nsid
Tight
Leaked ❑
osid
nsid
55 eol
RP- ' • 7 sid
If
Leaked ❑
Did not Open ❑
Leakeed C3
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
___ esid
Repair
Tight ❑
t>sid
nsid
RP sid
The above is certified to be true.
Firm Name Am eric as Af fd . S/!r i a- k1e P Certified Tester
Firm Address 60 v S Q,- ,Cc S& Cert. Tester No. Ef" -b /gf Date �=
Gauge # e7619/7S2-
Date last accuracy tested /Z -(Z. —12
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy