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2013_0122 (8)CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: The back-flow prevention assembly detailed beYow 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 �t ,M. C-? Model Number Serial Number . , �' -) 77 TYPE OF ASSEMBLY C Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker I o Size Located At i�4q �- The above is certified to be true. Firm Name��? certified Tester Chi�SZ as 05 Firm Address 7 5-0'/0 Cert. Testa No,,i"'I)Q] 07D Date Gauge #222 3 -5-3 Date last accuracy tested/ - ©? .-D - 2613 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 �k Opened at Opened at vsid Tight Z Leaked 12 ttsid vsid �a"3 RP- , .. sid Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at vsid Repair Tight ❑ nsid vsid RP sid The above is certified to be true. Firm Name��? certified Tester Chi�SZ as 05 Firm Address 7 5-0'/0 Cert. Testa No,,i"'I)Q] 07D Date Gauge #222 3 -5-3 Date last accuracy tested/ - ©? .-D - 2613 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy