2013_0411 (7)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ✓
BACIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # Q
LOCATION OF SERVICE: B — V o
C_ 1zv
t_ � �)(
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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer F T,8c, U Size
Model Number e? 05 Y Located At t E SE'R �C�?Jl -Jt
Serial Number
The above is certified to be true.
Firm Name') 04 I Fi Re
Firm Address -710cl (f A� q '5 .
Lew \k i'`? "%s� � - 7
Gauge #
Date last accuracy tested _7 i W
Certified Tester "'\1 C`*'( 1
f,,.(r #:1.1
CerG Tester Na '� 917 Date I)
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 e
Opened at
Opened at
osid
Tight ❑
Leaked ❑
osid
nsid
RP- psid
Leaked ❑
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') 04 I Fi Re
Firm Address -710cl (f A� q '5 .
Lew \k i'`? "%s� � - 7
Gauge #
Date last accuracy tested _7 i W
Certified Tester "'\1 C`*'( 1
f,,.(r #:1.1
CerG Tester Na '� 917 Date I)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy