2013_0613 (14)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE %t
NAME OF PWS- CITY OF COPPELL
PWS I.D. 9
LOCATION OF SERVICE:.
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 pararneters.
TYPE OF ASSEMBLY
G Reduced Pressure Principle C Pressure Vacuum Breaker
' % Double Check Valve C Atmosphere Vacuuni Breaker
✓
/f
Manufacturer size
Model Number Located At 5,
/(-j- cox /-t
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEM13LY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
-1st Check
2nd Check-
Relief Valve
Air Inlet
Check Valve
Initial Test
DC•Closed
Closed Tight
Opened at
Opened at
psid
Tight -
Leaked
_psid
sid
11
RP- osid
Leaked o
Did not Open 0
Leaked rl
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight C3
Opened at
Opened at
__ _—.psid
Repair
Tight
psid
psid
RP__---psid
The above is certified to be true.
Finn Name Certified Tester
/ / - - 1 '7
,/ /, t, , -�,4 - 7 �ev �
Firm Address X , ,) Cert. Tester No. /�&, , / c - Date
Gauge # �, % & a tl ) 7 -�/ 61
e- , -,
Date last accuracy tested / �;, "),-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy