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CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE_X
13ACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 3S-0 ) k
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
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer k/ " I V , , <, Size A
Model Number J� �y -� A
Serial Number 3q7,-)6
Located At At• I/,- - / t`
The above is certified to be true.
Firm Name : (4 Pr, i u j &i r (( iXA.:
Firm Address '�'5 (3
Gauge # 61 d 2 Z 2 q L'
Date last accuracy tested
?1
Certified Tester
Cert. Testa No, g ,51, Date
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 ❑
Opened at
Opened at
nsid
Tight ❑
Leaked Cl
psid
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name : (4 Pr, i u j &i r (( iXA.:
Firm Address '�'5 (3
Gauge # 61 d 2 Z 2 q L'
Date last accuracy tested
?1
Certified Tester
Cert. Testa No, g ,51, Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy