2013_1011CHECK ONE;
IRRIGATION DOMESTIC i� FIRELINE
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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
i„_� Double Check Valve
Manufacnaer
Model Number ego ,,7lam( l cp T
Serial Number 5-601
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size
Z ri
Located At Al.
REDUCED PRESSURE PRINCIPLE ASSEMBLY I PRESSURE VACUUM 13REM
Double Cluck Valve Assembly
let Check /. 2nd Check 'Z i'2- Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight Opened at Opened at id
Tight Leaked ❑ _psid �psid
RP -____j3sid
Leaked ❑ Did not Open ❑ Leaked ❑
Repairs
and
Materials
Used
TestAfkar I DC-Closed ❑ Closed Tight ❑ I Opted at I at I �id
The above is certified to be rue.
Firm Name �i r. f-r ►cA
Firm Address PO 8 v)A- 792
-)ry- 7Slh
Gauge # d7y9Z,,4 f9
Date last accuracy tested-6-//-13
Certified Tester /44e ✓t P7`L=
Cent. Testa No. S1'0'&O b 119"7 Date
White - Customer% Copy Yellow - City Copy Pink - Tester's Copy