2013_0411 (11)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L ��Vf�. ; y . pf�hurj lV�
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
f
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �� G 6> Size
Model Number Located At f-, R t k j s e- R Room
Serial Number R < 3119
The above is certified to be true.
Firm Name 7-of41 7�1 R
Firm Address 7109 A A
U NOS
Gauge # 3 3 � 7 S�
Date last accuracy tested 7
Certified rester
Cent. Tester No. `W�N y `I Q D=4/11/13
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
nSid
Tight ❑
Leaked ❑
psid
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
nSid
RP sid
The above is certified to be true.
Firm Name 7-of41 7�1 R
Firm Address 7109 A A
U NOS
Gauge # 3 3 � 7 S�
Date last accuracy tested 7
Certified rester
Cent. Tester No. `W�N y `I Q D=4/11/13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy