2013_0613 (15)CHECK ONE:
DOMESTIC
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
FIRELINE x
I as) I J 31 ;W *IV i
LOCATION OF SERVICE: 5 l 1-411),104
The back-ftow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
figfim• �:�
Reduced Pressure PrinciDle 0 Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At
Serial Number �Fi -f /j e2- r
L!±
Double Check Valve Assembly
DC-Closed
Tieht 5,, ►
RP------psid
Leaked
2nd Check I Relief Valve I Air Inlet
Valve
t� I Closed Tight � I Opened at Opened at t3sid
Leaked -- Psld --- Mid
The above is certified to be true.
Firm Name Certified Tester A,
Cent. Tester No. Date 6
Firm Address-/� 61,41
Gauge # c c c-11 7 1&
Date last accuracy tested �' - /
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy