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2013_0122 (6)CHECK ONE: IRRIGATION DOMESTIC FIRELINE yV- BAOULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: 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. C Reduced Pressure Principle fit+ Double } Check Valve Manufacturer Model Number Serial Numlber TYPE OF ASSEMBLY C! Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size I Located At c')-14 g L The above is certified to be true. 71iii Gauge #3-7,x-3,s-3 Date last accuracy tested /-o'?o`l -a ®i3 .. _ . /L1 ,� -!r... / M. /AM0 a. White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Double Check Valve Assembly 1st Check tad Check Relief Valve Air Inlet Check Valve Initial Test DC- Closed Closed Ti Opened at Opened at -- id R:!35 TiW4 )r RP -=L psid Leaked ❑ Leaked C3 © psid _psid Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at _psid Repair Tight p sid psid RP sin The above is certified to be true. 71iii Gauge #3-7,x-3,s-3 Date last accuracy tested /-o'?o`l -a ®i3 .. _ . /L1 ,� -!r... / M. /AM0 a. White - Customer's Copy Yellow - City Copy Pink - Tester's Copy