2013_0716 (11)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE I LZ
BACIILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE -A4 e C 6:se,
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
❑ Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C; Atmosphere Vacuum Breaker
Size
Located At fGb/h��S /r(/i
The above is certified to be true.
Firm Name / /e / YD .
Fins Address 1'0'6,12,6-) L/I 464le,/�i�a
7x 7 6609
Gauge # L� 46 d 4/0 S-1 -0
Date last accuracy tested �d
Certified Testa
Cert. Testa No. !� 1°� `� Date ?117e T13
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
osid
Tight �� c/) ❑
Leaked ❑
osid
vsid
RP- ._,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name / /e / YD .
Fins Address 1'0'6,12,6-) L/I 464le,/�i�a
7x 7 6609
Gauge # L� 46 d 4/0 S-1 -0
Date last accuracy tested �d
Certified Testa
Cert. Testa No. !� 1°� `� Date ?117e T13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy