2013_0716 (19)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE'
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: A_ ✓GUi r ',;�� r� �i� se ��f5'i`` le
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
e Reduced Pressure Principle C Pressure Vacuum Breaker
0 Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer %J/ �� h =�_ Size
Model Number D X�
Serial Number
Located At , }' l S� Y ; �.�/ >�C,7'
The above is certified to be true.
Firm Name Ae t Y) 60/w/111
Firm Address & 6 /, G ? (r n :, Q
�� ;�Ga9 4
Gauge # ®'j Co '-/0 SS'O
Date last accuracy tested A U %�
Certified Testa J e r
Cat. Testa No. �.m"'eo g,(' o Date r l
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 ;Z ❑
RP -_psid
Leaked ❑
°
nsid
osid
Leaked ❑
Did not Open ❑
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name Ae t Y) 60/w/111
Firm Address & 6 /, G ? (r n :, Q
�� ;�Ga9 4
Gauge # ®'j Co '-/0 SS'O
Date last accuracy tested A U %�
Certified Testa J e r
Cat. Testa No. �.m"'eo g,(' o Date r l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy