2013_0122 (12)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE -
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
5Z Double Check Valve
Manufacturer C`' i
Model Number r°L'
Serial Number L) S -5 L -)-- _
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At � -'" �� i cA
The above is certified to be true.
Firm Name te. �� /� Certified Tester/
,aC20� 2 CK
Firm Address �� c1 - -75-041-) Cert. Tester No.,V00161-13 Date s-; 13
Gauge # 3 7,4 3 5 3
Date last accuracy tested/ 20 -/ 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCE
Double Check Valve Assembly
1st Check
2nd Check
Initial Test
DC- Closed
Closed Tight
5
Tight G-
RP- i 4sid�
Leaked ❑
Leaked
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight
Repair
Tight t7
RP sid
The above is certified to be true.
Firm Name te. �� /� Certified Tester/
,aC20� 2 CK
Firm Address �� c1 - -75-041-) Cert. Tester No.,V00161-13 Date s-; 13
Gauge # 3 7,4 3 5 3
Date last accuracy tested/ 20 -/ 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy