2013_0122 (40)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: — 100 - /l k1k Y LEY—,
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
'19-- Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
�'�- 5 I i
Manufacturer Size
Model Number
��C� ' Located At
Serial Number t [ C ,p
The above is certified to be true.
Firm Named -/1 Certified Tester ��Z/�
19 -� O s
Firm Addrew az��n -��% 75 c3 416 Cert. Tester No -AP601 y 7 73 Date 2 13
Gauge # 3 V7 --� 3 5 3
Date last accuracy tested/ '-a Q, 4
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
nsid
Tight A
Leaked ❑
nsid
nsid
RP-_1 sid
Leaked o
Did not Open O
Leaked
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Named -/1 Certified Tester ��Z/�
19 -� O s
Firm Addrew az��n -��% 75 c3 416 Cert. Tester No -AP601 y 7 73 Date 2 13
Gauge # 3 V7 --� 3 5 3
Date last accuracy tested/ '-a Q, 4
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy