2013_0613 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE x
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 5 0/ /-/i? A00 e ct. L
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
r-
14
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double T Check Valve
�{ ° /`E 1-3
% 7
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
ir
Size
Located At
q
The above is certified to be true.
Firm Name A l L %- f�' t'
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAICER
Double Check Valve Assembly
Firm Address P ,ti. ALT X 7 1 % 1'✓4 Y19
)'-" Cat Testa No.
1��1 c "' ° > €.� �
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight 3, 8 t(
RP- .__psid
Lza;e ❑
Closed Tight )�
Leaked ❑
�-
Opened at
psid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
� sid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name A l L %- f�' t'
Certified Testa
Firm Address P ,ti. ALT X 7 1 % 1'✓4 Y19
)'-" Cat Testa No.
1��1 c "' ° > €.� �
Date
Gauge # & C, i? c/ / J �` G
Date last accuracy tested -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy