2013_0716 (14)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE L-"
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ! l S rQ- , /IC -.5.6 ' X xr,00 <<
The backflow 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 C; Atmosphere Vacuum Breaker
Manufacturer L4- h S Size .2
Model Number C9 S0 xL Located At��
Serial Number �o J-3 7J Z
The above is certified to be true.
Firm Name t4 'YG L D/?'I A'I
Firm Address /°D —avLad
7x' 2W 99'
Gauge # ' - )V6Y,SO
Date last accuracy tested %S11C1z
Certified Tester J e Y r � /C
Cert. Tester No. :fft,4 56 0 9 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
osid
Tight ❑
RP -_psid
Leaked ❑
vsid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight Cl
psid
osid
RP sid
The above is certified to be true.
Firm Name t4 'YG L D/?'I A'I
Firm Address /°D —avLad
7x' 2W 99'
Gauge # ' - )V6Y,SO
Date last accuracy tested %S11C1z
Certified Tester J e Y r � /C
Cert. Tester No. :fft,4 56 0 9 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy