2013_0122 (26)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE A
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �( f's b � L ip - /0017
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
t�
Manufacturer Size
Model Number Located At C-
Serial Number i L
The above is certified to be true.
Firm N _ 1��,V
Firm Address —ZZ6 1/0
Gauge # 3 7-2.3 S--3
Date last accuracy tested /, , /,
Certified Tester 2L1i/i &1z1oAa
Cert. Tester Nog?�d a 107 73 Date i ' a 5. 13
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 V,
Opened at
Opened at
esid
Ti� k
RP -_ psid
Leaked ❑
Leaked ❑
° '°
osid
_nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
,_nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm N _ 1��,V
Firm Address —ZZ6 1/0
Gauge # 3 7-2.3 S--3
Date last accuracy tested /, , /,
Certified Tester 2L1i/i &1z1oAa
Cert. Tester Nog?�d a 107 73 Date i ' a 5. 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy