2013_0716 (7)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE tom'"
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVIC sc. f.32L6- ✓&-rC"LI? 1),e-
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
❑ Double Check Valve � Atmosphere Vacuum Breaker
Manufacturer ` 1/i! //"� ! f%s Size
Model Number �- Located At Yl SG Y J-A , / 7 a
Serial Number
The above is certified to be true.
Firm Name ffe f /v re -,!71 gl ,
Firm Address P�, / l 2G 71r. d
760
Gauge # '113111 1-16 1'15 5 0
Date last accuracy tested /D /p J
Certified Tester :S-I? r r�
Cert. Tester No!'31° eai6 G q Date /i f
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 ❑
DSid
nSid
_?,6
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name ffe f /v re -,!71 gl ,
Firm Address P�, / l 2G 71r. d
760
Gauge # '113111 1-16 1'15 5 0
Date last accuracy tested /D /p J
Certified Tester :S-I? r r�
Cert. Tester No!'31° eai6 G q Date /i f
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy