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2013_0411 (8)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACK MOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # CATION OF SERVICE: � �� `�� `' B, v Lt Cof`. 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 C Pressure Vacuum Breaker C Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer 75 ` t c y Size 1 yz Model Number V5, Y Located At F� t Serial Number The above is certified to be true. Firm Name fi ©W Firm Address Gauge #? 3 1799 Date last accuracy tested -7/f M �- Certified Tester Cert. Tester No. 'Y 1 t-{Q 17 Date l�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 ❑ Opened at Opened at vsid Tight ❑ RP-_ —Psid Leaked ❑ vsid vsid Leaked ❑ Did not Open O Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at vsid Repair Tight ❑ vsid osid RP sid The above is certified to be true. Firm Name fi ©W Firm Address Gauge #? 3 1799 Date last accuracy tested -7/f M �- Certified Tester Cert. Tester No. 'Y 1 t-{Q 17 Date l�I White - Customer's Copy Yellow - City Copy Pink - Tester's Copy