2013_1011 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /110
11
The backftow 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
6e Double Check Valve o Atmosphere Vacuum Breaker
pig
Manufacturer �.h4z:!' ��`— -- Size o
Model Number C d c, �T Located At
Scrial Number Igo g- S 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check 3. Z.-
2nd Check 7-'6
Initial Test
DC- Closed
Tight 12,11,
Closed Tight ►tai
Leaked o
Opened at
�nsid
Opened at
� d
--osid
RP- r.,psid
Leaked o
Did not Open O
Leaked O
Repairs
and
Matmiais
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
� d
Opened at
_ asid
paid
RP
The above is certified to be true.
fj j
Firm Name ,L Certified Tester
Firm Address Pa 8 PV- 7,9'--/-' Cat. Tester No. S19vf b 151 Date ° 3
�J --).o -f . ?sib �
Gauge # a ?pja 4,'9
Date last accuracy tested ~ % /J i3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy