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2013_0716 (22)CIIECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICENO— jYa el verc,�f re /? 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 /-j J- Zi�ll/1, 5 Size Model Number 9-'!�4 kz, Serial Number �) Y %a Located At �(! ESQ Y r3'D!7/71f�s The above is certified to be true. Firm Name .�%IIV Firm Address #40d�a2 &,LWa u/i y /x ?If 09 r Gauge # 409Pz1©Sr50 Date last accuracy tested Certified Tester'' -r r Judd � j Cent. Testa No. /�fg(c (o �1' Daw? 1i& (% 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 nsid Tight ❑ RP -_pSid Leaked ❑ , psid nSid Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at nsid Repair Tight ❑ nsid nSid RP Sid The above is certified to be true. Firm Name .�%IIV Firm Address #40d�a2 &,LWa u/i y /x ?If 09 r Gauge # 409Pz1©Sr50 Date last accuracy tested Certified Tester'' -r r Judd � j Cent. Testa No. /�fg(c (o �1' Daw? 1i& (% White - Customer's Copy Yellow - City Copy Pink - Tester's Copy