2013_0710 (2)CHECK ONE:
IRRIGATION �( DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 50,1
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 C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer 11&1 f 15- Size
Model Number e O ✓ If l
Serial Number � 5 Y ;7 l _
Located At -5 1-Z- cd X AC- e c.
The above is certified to be true.
Firm Name y�c
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm Address
x
% 5' 7
tlrr3 x %1. T,xCat Tester No. ec'c'e /a- Date 2 -/0 `•�
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight /- I
RP -_psid
Closed Tight
Leaked /; C/ C
Opened at
osid
Opened at
osid
osid
Leaked C
Did not Open o
Leaked D
Repairs
and
Materials
Used
TesL
DC- Closed
Closed Tight o
Opened at
Opened at
_ nsid
RepTight
o
psid
osid
RP sid
The above is certified to be true.
Firm Name y�c
I/ e
Certified Testa ✓ ?� � "� GG�; %�� �9 ear -�
Firm Address
x
% 5' 7
tlrr3 x %1. T,xCat Tester No. ec'c'e /a- Date 2 -/0 `•�
Gauge # 6.16 & `,/ / 7
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy