2013_0613 (12)CHECK ONE:
IRRIGATION-4— DOMESTIC FIRELINE
1BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: S (:!2 �I X A let C cell
'The bac0ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Gauge # 0 t 0 1--// -.2 9 C-
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEM13LY
lit
Double Check Valve Assembly
Relief Valve
DC-Closed
Closed Tight 0
Opened at
Tleht 0
Lcak-ed
Sid
1.,eakod
Did not Open
Repairs
and
Materials
Used
DC-Closed
TiOt
The above is certified to be true.
Finn Name
Certified Tester L11
Firm Address
f 0 o )i
Cert
Tester No. 9P00019-7e)--,-1 Date
Gauge # 0 t 0 1--// -.2 9 C-
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy