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2013_0716 (17)
CIIECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: � 1a &g1, (C�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. TYPE OF ASSEMBLY C Reduced Pressure Principle 12 Pressure Vacuum Breaker D Double( Check Valve G Atmosphere Vacuum Breaker Manufacturer /� // Size Model Number Located At Serial Number The above is certified to be true. Firm Nam 60.0i yr Firm Address P491Alo 2 T �l0 Gauge # © 9O ya Rs4 j Date last accuracy tested 1011e)11-47 Certified Tester Cert. Tester No. �IO" Y6 6e .'F 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 42 Closed Tight -42r' Opened at Opened at nsid Tight ;,gyp .e RP -._ -psid Leaked ❑ j, 7 nsid nsid Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at nsid Repair Tight ❑ psid nsid RP sid The above is certified to be true. Firm Nam 60.0i yr Firm Address P491Alo 2 T �l0 Gauge # © 9O ya Rs4 j Date last accuracy tested 1011e)11-47 Certified Tester Cert. Tester No. �IO" Y6 6e .'F Date White - Customer's Copy Yellow - City Copy Pink - Tester's Copy