2013_0716 (20)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAOCMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: r'l31.��'s aR/4. . /3/ 5 A4) verc,
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 ❑ Pressure Vacuum Breaker
Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer s Size
Model Number Located At��� ►� 1��/D%X %G�_
Serial Number An 2 12 1�7 Z-.!
The above is certified to be true.
Firm Name /7/,e i Y-e,
Firm Address Pa1312G 9 &rco e U=
Gauge # Q g(0 Vog 5-)
Date last accuracy tested/
Certified Tester P Y r'ci -5-c /e / ,O k
Cert. Tester No.13/10 Date 211,3
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 o
osid
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 ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name /7/,e i Y-e,
Firm Address Pa1312G 9 &rco e U=
Gauge # Q g(0 Vog 5-)
Date last accuracy tested/
Certified Tester P Y r'ci -5-c /e / ,O k
Cert. Tester No.13/10 Date 211,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy