2013_0710 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE K-
BAMLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: F(�/'
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.
C Reduced Pressure Principle
CSC' Double Check Valve
Manufacturer 9/if fl S
Model Number 7 7 L/ X
Serial Number %F e" =" 2/
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
�C
Size
Located At /I/ ,-• (::° yt' ex v t1l
The above is testified to be true.
Firm Name 194C taw, Certified Tester
Firm Address 7 ' tert Tester No. /j a0c,^074 — Date 7 '`la
Gauge #
Date last accuracy tested 9 _ 5-
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
Tight 3 & X
Closed Tight ZQ'
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP -_ psid
3
Leaked ❑
Did not Open ❑
Leaked ❑
and nd �
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is testified to be true.
Firm Name 194C taw, Certified Tester
Firm Address 7 ' tert Tester No. /j a0c,^074 — Date 7 '`la
Gauge #
Date last accuracy tested 9 _ 5-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy