2013_0122 (35)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE Y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # !!11
LOCATION OF SERVICE: ldcdi
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
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer dAiln� C - Size
Model Number Located At
—T 1_
Serial Number �t
The above its certified to be true.
Firm Name`" a C-4,072 11LL. A:d
Firm Address /CIL�/ I x 7S y4�c
Gauge #3 `7., 3 .5 -3
Date last accuracy tested / ,2,2-- 1,3
Certified Testes C` C
Cat Testa No.LVT)AD /6 -11-S Date 1 ` -,)- S ` 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
Tight V
Rp- t -f5 Dsid
Leaked ❑
Closed Tight `a
Leaked ❑
E
Opened at
osid
Opened at
oSid
Did not Open O
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight Cl
Closed Tight C3
Opened at
vsid
Opened at
t?Sid
oSid
RP nsid
The above its certified to be true.
Firm Name`" a C-4,072 11LL. A:d
Firm Address /CIL�/ I x 7S y4�c
Gauge #3 `7., 3 .5 -3
Date last accuracy tested / ,2,2-- 1,3
Certified Testes C` C
Cat Testa No.LVT)AD /6 -11-S Date 1 ` -,)- S ` 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy