2013_0910 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE x—
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /S - �4 S SJ ,/%�Tfc,' L r A 9
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
'g Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer AdA Size
Model Number A M Located At A, i SinE Ar �'/1�,._,1AJ V,41Q —r
Serial Number � qLl 7
The above is terrified to be true.
Firm Address
Cft &,Z, L 7V /U, 7 Z'6'7
Gauge #
Date last accuracy tested // -1) r%a
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
nsid
Check Valve
nsid
Did not Open ❑ 1 Leaked ❑
Opened at I sid
nsid
Cert. Taster No. 'I'alaC /�C %�� Date g
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Initial Test
DC- Closed
Tight �
RP- li Dsid
Leafed ❑
Closed Tight �-
Leaked o
r
Opened at
nsid
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
RP sid
The above is terrified to be true.
Firm Address
Cft &,Z, L 7V /U, 7 Z'6'7
Gauge #
Date last accuracy tested // -1) r%a
PRESSURE VACUUM BREAKER
Air Inlet
Opened at
nsid
Check Valve
nsid
Did not Open ❑ 1 Leaked ❑
Opened at I sid
nsid
Cert. Taster No. 'I'alaC /�C %�� Date g
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy