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2013_0208
CHECK ONE: IRRIGATION DOMESTIC FIRELINE x BACKILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: ©® Or�-9 F ,0® /e r- yl�k W- The bacidlow 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 Reduced Pressure Principle ❑ Pressure Vacuum Breaker Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer IL °`A rr-$ Size Model Number % —/ t/ x D c-' .4 Serial Number %G' oS 9 -1 " o z ef .1 Located At Uil e s T 3" '04 8t D The above is certified to be true. Firm Name , �G -� "5 1-f 0'' f . ,s, X— Certified Testa ja '09 & Aer- 9'91 Firm Address 7S !o9' ra Cat. Testa No. .BFao13 / -0f' Date Zf Gauge # t$ C Z & y y Date last accuracy tested Z -S- ZcsIJ 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 ,� 7 s 5 DC- Closed Tight d` RP- l -/ tasid Leaked ❑ Closed Tight e( Leaked C3 r„ 4 Opened at nsid Opened at osid Did not Open ❑ osid Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at _ nsid Repair Tight ❑ nsid osid RP sid The above is certified to be true. Firm Name , �G -� "5 1-f 0'' f . ,s, X— Certified Testa ja '09 & Aer- 9'91 Firm Address 7S !o9' ra Cat. Testa No. .BFao13 / -0f' Date Zf Gauge # t$ C Z & y y Date last accuracy tested Z -S- ZcsIJ White - Customer's Copy Yellow - City Copy Pink - Tester's Copy