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2013_0613 (9)
CHECK ONE: IRRIGATION K DOMESTIC FIRELINE BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: 9 0 / /-/,I l4 94 0 1-t � 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 Manufacturer Model Number Reduced Pressure Principle Double Check Valve i= c�13�b K 50 Serial Number /-/ © / / / !7 TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size - -- Located At / k, le r OX yt- e eL ,, � Xf -e ie4,. The above is certified to be true. /// Firm Name /) c � o k �/X P Certified Tester LIZ' /('c al ` '1 ,W 3 Firm Address P /3v x 7 Y 7 TCxc L Tester No. i3 /)�Jo o f'7 "Date G _ l 3 Gauge # orG 0 �1/ / YO Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Ist Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight ❑ Opened at Opened at nsid Tight ❑ Leaked ❑ nsid nsid RP- __psid Leaked ❑ Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight c3 Opened at Opened at nsid Repair Tight ❑ nsid nsid RP sid The above is certified to be true. /// Firm Name /) c � o k �/X P Certified Tester LIZ' /('c al ` '1 ,W 3 Firm Address P /3v x 7 Y 7 TCxc L Tester No. i3 /)�Jo o f'7 "Date G _ l 3 Gauge # orG 0 �1/ / YO Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy