2013_1011 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAMLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 11to do
ge;(4 a [4
The backflow prevention assembly detailed below has been testers and mammined, as required by TNRCC
regulations and is certified to be operating within acceptable pis.
C
k
Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
7,rq de d
Serial Number
//2„- ? 3
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ist Check , ► tad Check 1-,9 Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight t e'' Opened at Opened at __—*d
Tight Leaked ❑ _psid ------.Paid
RP -_psid
Leaked ❑ Did not Open ❑ Leaked O
Repairs
and
Materials
Used
Repair I lased ❑ Closed Tight o I at at —� d
The above is cerdfied to be mm.
Firm Name /a ,62
Firm Address PO 13 vV-- 792
l�J A -79- �Slh
Gauge # d? 6 9 a 4 d'9
Date last accuracy tested 6-11-)3
Certified Testes ✓i e-t
Cert. Testa No. Maft 6/5-71)= /° -11 ' 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
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