2013_0716 (21)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: ��i� "✓r ;�a;s� /3/ 5:'v�,tc ��;sr I�'
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 a Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer /�� / /`' /'t 4 Size
Model Number 96-/ SCL� Located At f sz° ,r Dix
Serial Number -i
The above is certified to be true.
Firm Name we /YV Cc,-Arr i Certified Tester
Firm Address /r % �r rL� ' E' Cert. Tester No. DD��G Date
Gauge # _Q 8C' X16; ()
Date last accuracy tested 1!%llJl2-
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 o
Opened at
Opened at
oSid
Tight a
Leaked ❑
osid
oSid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
psid
oSid
RP sid
The above is certified to be true.
Firm Name we /YV Cc,-Arr i Certified Tester
Firm Address /r % �r rL� ' E' Cert. Tester No. DD��G Date
Gauge # _Q 8C' X16; ()
Date last accuracy tested 1!%llJl2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy