2013_1024 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIO'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 01- U— A i(,
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.
❑ Reduced Pressure Principle
❑ Double Check Valve
Manufacturer C L, C
Model Number C C
Serial Number q I �i 1223
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size 4"
Located At li �i, U). ( U E hl L ) y', AU LT
The above is certified to be true.
Firm Name `--MA N (4 "AC L Certified Tester
Firm Address 1Q -1, E . CbAML �j . Cert. Tester No. `1 V1-I Date q,A -�
--c► �J 77 1 X0 l
Gauge # iiLkClgC�1A0 j
Date last accuracy tested 12 e
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 ❑
psid
oSid
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name `--MA N (4 "AC L Certified Tester
Firm Address 1Q -1, E . CbAML �j . Cert. Tester No. `1 V1-I Date q,A -�
--c► �J 77 1 X0 l
Gauge # iiLkClgC�1A0 j
Date last accuracy tested 12 e
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy