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2013_0716 (15)CHECK ONE: IRRIGATION DOMESTIC FIRELINE, y BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICERXou , 's a s 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. C Reduced Pressure Principle ❑ Double Check Valve Manufacturer - 4)j /,L %? 5 Model Number 195-0 , Serial Number 996 TYPE OF ASSEMBLY • Pressure Vacuum Breaker • Atmosphere Vacuum Breaker Size J Located At 9A The above is certified to be true. Firm Name Altxd From Address %P V, n �> 7'x 7 0 Gauge # ' F0 yo ?moo Date last accuracy tested /—e el Certified Tester Cent. Tester No. /�I�DD ©�� 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 ❑ Leaked ❑ nsid osid RP- __psid Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at osid Repair Tight ❑ osid osid RP sid The above is certified to be true. Firm Name Altxd From Address %P V, n �> 7'x 7 0 Gauge # ' F0 yo ?moo Date last accuracy tested /—e el Certified Tester Cent. Tester No. /�I�DD ©�� Date White - Customer's Copy Yellow - City Copy Pink - Tester's Copy