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2013_0122 (9)
CHECK ONE: IRRIGATION DOMESTIC FIRELINE yr BACxYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: - /D D The backflow prevention assembly detailed below has been tested and mamtamed as required by TNRCC regulations and is certified to be operating within acceptable parameters. C Reduced Pressure Principle Double Check Valve Manufacturer C`C Model Number Serial Number I TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker © Atmosphere Vacuum Breaker Size Located At �,Li L - 6e 1-+L _ The above is certified .. ..+ / ' / Cafffied Gauge #37,a-3,s-3 Date last accuracy tested /- o?a -aoi3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly Ist Check 2nd Check: Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Tight A Opened at Opened at osid R � 5 Tight CI) 0 1 RP - sid Leaked ❑ Leaked C3 ' __^ sid _ osid Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at _osid Repair Tight p sid �psid RP sid The above is certified .. ..+ / ' / Cafffied Gauge #37,a-3,s-3 Date last accuracy tested /- o?a -aoi3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy