2013_0122 (16)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE k
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: d ZeQ 7
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 C Pressure Vacuum Breaker
`,E Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer 0 - Size
Model Number .,';C Located At
Serial Number C-5 Ct ^ )'
The above is certified to be true.
Firm S � c�c zn
Firm Address -7 40
Gauge # 3 2 2 3 S-3
Certified Tester %%�a,e b r? Aaii /irl /l
Cert. Testa Na -f-W I Q Date 5'-09,5-220/3
Date last accuracy tested / - 2 2 - o2O13
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
C , SS
DC- Closed
Ti '®
RP• :� sid
Leaked p
Closed Tight S
Leaked o
, G
Opened at
osid
Opened at
osid
Did not Open o
osid
Leaked
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight t7
Closed Tight o
Opened at
osid
Opened at
osid
------- csid
RP sid
The above is certified to be true.
Firm S � c�c zn
Firm Address -7 40
Gauge # 3 2 2 3 S-3
Certified Tester %%�a,e b r? Aaii /irl /l
Cert. Testa Na -f-W I Q Date 5'-09,5-220/3
Date last accuracy tested / - 2 2 - o2O13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy