2013_0613 (10)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BA "LOW PREVENTION ASSEM33LY TEST AND MADITENANCE REPORT
NAME OF PW& CITY OF COPPELL
PWS I.D. 4
LOCATION OF SERVICE:
. . Y
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cadfied to be operating within acceptable parameters.
tsV
Reduced Pressure Principle
Double Check Valve
Manufacturer
11r —
Model Number
Serial Number
TYPE OF ASSEMBLY
0 Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size —2
Located At
The above is certified to be true.
Firm Name Al /1 1,.- / f / A -r C a t
ertified Test
Firm Address 7 Yl Cat Testa No. Date
Gauge # 0 f 7
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
Double Check Valve Assembly
DC-Closed
•IIII at
Tight
Iti---psid
Leaked
Did not Open
C3 i
Repaim
tnd
matMrials
Used
DC-Closed
Tight C3
The above is certified to be true.
Firm Name Al /1 1,.- / f / A -r C a t
ertified Test
Firm Address 7 Yl Cat Testa No. Date
Gauge # 0 f 7
Date last accuracy tested
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy