2013_0910CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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
g Double Check Valve OETEC7-e'k ❑ Atmosphere Vacuum Breaker
Manufacturer —b )A T7TS Size
/c, I
Model Number 1760 n(J) Located At FAST ,S/ /) L r, F�Q, iVlgtte I
Serial Number / 1 ?y1L
The above is certified to be true. aik- Cgs----e
Firm Name X#-A - A(',a'/ i k -i:2 LZe (,1 Certified Testa Lfi M-16 H ,r% t'-2,2 10
Firm Address 111/Zd y /SRI Cert. Testa No. Date
/X 7�Z,0 7
Gauge # 3
Date last accuracy tested _ / % 27 /,-)
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 1g(
RP- � 3, /,,- Dsid
Closed Tight X
Leaked ❑
Opened at
nsid
Opened at
psid
osid
.
Lza;ed ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test Mier
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
___osid
RP sid
The above is certified to be true. aik- Cgs----e
Firm Name X#-A - A(',a'/ i k -i:2 LZe (,1 Certified Testa Lfi M-16 H ,r% t'-2,2 10
Firm Address 111/Zd y /SRI Cert. Testa No. Date
/X 7�Z,0 7
Gauge # 3
Date last accuracy tested _ / % 27 /,-)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy �/�