2013_0327CHECK ONE:
IRRIGATION DOMESTIC V FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # AjjeL
pPrk-
LOCATION OF SERVICE: I I I I FQ*E POrT W
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
9' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer y►J tt K w s
Model Number
Serial Number
gi015V
Size
Located At
3
etre p_ISEr K6dM
The above is certified to be true.
Firm Name uss F n E Guar o
Firm Address 265
10 ►'''"•tU.'c►' 4.D
t)X111 AS ,-r i
Gauge # o t t" f q/
Date last accuracy tested !- 7 - 13
Certified Testa W !G Fre d ,r. 60m e Z
Cert. Testa No. SP0013 0'y Y Date -3-2--7-1.?
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 !. 5
Closed Tight W
Opened at
Opened at
nsid
Tight 9'
Leaked ❑
nsid
nsid
JASS
RP- ,_,_psid
Leaked p
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
vsid
nsid
RP sid
The above is certified to be true.
Firm Name uss F n E Guar o
Firm Address 265
10 ►'''"•tU.'c►' 4.D
t)X111 AS ,-r i
Gauge # o t t" f q/
Date last accuracy tested !- 7 - 13
Certified Testa W !G Fre d ,r. 60m e Z
Cert. Testa No. SP0013 0'y Y Date -3-2--7-1.?
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy