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2013_0122 (29)CHECK ONE: IRRIGATION DOMESTIC FIRELINE A BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: 1i ce- The backfIow 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 2f Double Check Valve Manufacturer A4"'� (� <; Model Number C` Serial Number© Relief Valve TYPE OF ASSEMBLY C Pressure Vacuum Breaker o Atmosphere Vacuum Breaker Size Located At- The above is certified to be true. Firm Name - Firm Address i z 2 5140 Gauge #7235- "3 Date last accuracy tested /, 61a, / 3 Certified Testa „f lar l o ,Y] t-baa Cent. Testa No.60I �DI0 !73 Dateq-2-,S-,/-3 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 Opened at Opened at nsid rt -13 � Tight O RP_.Psid. Leaked o Leaked psid nsid Did not Open o Leaked E3 Repairs and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at _ vsid Repair Tight o nsid vsid RP sid The above is certified to be true. Firm Name - Firm Address i z 2 5140 Gauge #7235- "3 Date last accuracy tested /, 61a, / 3 Certified Testa „f lar l o ,Y] t-baa Cent. Testa No.60I �DI0 !73 Dateq-2-,S-,/-3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy