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2013_0613 (5)CHECK ONE: IRRIGATION_ DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: s © / //,,,I "el e "L, ,/ 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. e Reduced Pressure Principle i Double Check Valve Manufacturer &,,, - b Model Number e.,> & 7 Serial Number (9 / q TYPE OF ASSEMBLY Q Pressure Vacuum Breaker C1 Atmosphere Vacuum Breaker ,/ Size iii Located At 5 L' c- e A K e "_ 4 f /u e f e,.( The above is certified to be true. Firm Name / -e hiv tv REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Firm Address P e). 1.3 ;r 7l ? )(A rCerL Tester No. l3Oaac� i Due 1st Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Tight 2' -;� IV Closed Tight Leaked �e� ❑ Opened at osid Opened at oSid osid RP -_psid Lza;ed, Cl Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at _____.p sid Repair Tight ❑ nsid oSid RP sid The above is certified to be true. Firm Name / -e hiv tv f L Certified Tester Firm Address P e). 1.3 ;r 7l ? )(A rCerL Tester No. l3Oaac� i Due Gauge # 060 Y/ 1 `l O Date last accuracy tested Y - S / 3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy