2013_0122 (31)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
% Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer f41tv\ C 5 sue
Model Number t9LIQ C Located AA2 C? L 't b f-5 iA i A (ac F C�-Q F-y
Serial Number 1 . � 1
The above is certified to be true.
Firm Name �� c4 " d . alk
0- a b s' cz- � CA-
Firm Addr ss��and,1v- -7,Y-O `f b
Gauge# 370353
Date last accuracy tested
I -aa• 13
Certified Tester `njarL Zx tSderdL`Zr,,,'7j
Cert. Tester No 6 l 773 Date
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 R
Opened at
Opened at
nSid
pea55
Tight 'r
RP -2.:,a
Leaked ❑
Leaked ❑
` ° l
nSid
nSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
___.p sid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name �� c4 " d . alk
0- a b s' cz- � CA-
Firm Addr ss��and,1v- -7,Y-O `f b
Gauge# 370353
Date last accuracy tested
I -aa• 13
Certified Tester `njarL Zx tSderdL`Zr,,,'7j
Cert. Tester No 6 l 773 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy