2013_0716 (16)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: !TUL 'r'1/� ye 6 s
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ccrtified to be operating within acceptable parameters.
C Reduced Pressure Principle
C Double Check Valve
Manufacturer [�i
Model Number .SO kL_
Serial Number (Li/
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size / �/z
Located At )(I 'Z I" r00%m� /f
The above is certified to be true.
Firm Name l%? I Y"O (1-16
Firm Address �� /fit ?( Q
-'9
Gauge #
Date last accuracy tested/ Q� Xx
r
Certified Tester
Cert. Tester No: ?/! 8W FO Z 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
vSid
Tight ❑
RP -_pSid
Leaked �j ❑
oSid
oSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Ater
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
vSid
RP sid
The above is certified to be true.
Firm Name l%? I Y"O (1-16
Firm Address �� /fit ?( Q
-'9
Gauge #
Date last accuracy tested/ Q� Xx
r
Certified Tester
Cert. Tester No: ?/! 8W FO Z Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy