2013_1024 (2)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
'} W o iCZ%i t� SAO- , . k-- d .
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 parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
n Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer % 'S Ir _ Size �0 "
Model Number 3) C- M Located At 1IA all V E1tit(�i'�
Serial Number ?. % 4 c
The above is certified to be true.
Firm Name ; ��`��� �`i Certified Tester"
— �Ia�.�',
Firm Address C. COTTM ��i�� . Cent Tester No. CI�I Date tOL
0 � T7M
Gauge # ()Lj(J 0�13'
Date last accuracy tested L5X2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
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
osid
Tight ❑
Leaked ❑
osid
nsid
RP -_psid
5�,,
Leaked ❑
Z . S
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name ; ��`��� �`i Certified Tester"
— �Ia�.�',
Firm Address C. COTTM ��i�� . Cent Tester No. CI�I Date tOL
0 � T7M
Gauge # ()Lj(J 0�13'
Date last accuracy tested L5X2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy