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2013_0122 (8)
CHECK ONE: IRRIGATION DOMESTIC FIRELINE K BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL 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. TYPE OF ASSEMBLY ❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker z Double Check Valve ❑ Atmosphere Vacuum Breaker Manufacturer L41-4-L' 7 Size Model Number %�> Located At �- 4��' • '� L.�� Serial Number C-' The above is certified to be true. Gauge # 3 -72 3 5- 3 certified Tester -1WCZ2 �J'1 �c�» cG�Jrc JC Cat Tester N. 77-? Date 9' as-, a c r 3 Date last accuracy tested j - cq,-� - ©2 O /_3 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 Closed Tight k, Opened at Opened at psid Tight CIL RP- Leaked ❑ nsid nsid J J > sid Leaked ❑ ` ` Did not Open ❑ Leaked ❑ Repairs and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at nsid Repair Tight ❑ sid nsid RP sid The above is certified to be true. Gauge # 3 -72 3 5- 3 certified Tester -1WCZ2 �J'1 �c�» cG�Jrc JC Cat Tester N. 77-? Date 9' as-, a c r 3 Date last accuracy tested j - cq,-� - ©2 O /_3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy