2013_0613 (18)CHECK ONE:
IRRIGATION-
- - -0 -, I
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable param
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
5t Double Check Valve 174 Atmosphere Vacuum Breaker
tr
1j,
Firm Address P.O. 15 0 7 7'CcrL Tester No. tM'7,911 7 Date
Gauge # 6be Y/ / V 6) _
Date last accuracy tested 5' 3
White - Customer's Copy YeHow - City Copy Pink - Tester's Copy
Double Check Valve Assembly
I DC-Closed
Opened at
Opened at
Tight
psid
4 Sid
Leaked
Did not Open a
Repairs
and
Materials
Used
I DC-Closed
Opened at
Tight
p Sid
The above is
certified • be true.
AI'lle
1j,
Firm Address P.O. 15 0 7 7'CcrL Tester No. tM'7,911 7 Date
Gauge # 6be Y/ / V 6) _
Date last accuracy tested 5' 3
White - Customer's Copy YeHow - City Copy Pink - Tester's Copy