2013_0612 (2)CHECK ONE:
IRRIGATION v DOMESTIC
FIRELINE
�exev, ,t-# 13 ._2,5 7 9
BACIKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 7 17 PC m b ra ►r� d -I– C- '.
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
❑ / Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
fit; (s,
7350
Serial Number A ,-�!5 S V
3/cr �r
Size
r
Located At
The above is certified to be true.
�� dd pp ��� r/
Firm Name f
H'�1(�(� �_ac � 10O TAM , Certified Testa D6-L%-.'A
Firm Address l �SP�t I�j�T>< Cat. Tester Ni �� Date
Gauge # b6 05 DAY
Date last accuracy tested -7- (2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
nsid
Tight 3.0
Leaked � ❑
nsid
nsid
�- 2--)3
RP -___Lpsid
Z
Leaked p
Did not Open ❑
Leaked ❑
Reps
and
Materials
CU
0 fie—
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_____–p sid
Repair
Tight Cl
nsid
_nsid
J,
RP sid
M�
The above is certified to be true.
�� dd pp ��� r/
Firm Name f
H'�1(�(� �_ac � 10O TAM , Certified Testa D6-L%-.'A
Firm Address l �SP�t I�j�T>< Cat. Tester Ni �� Date
Gauge # b6 05 DAY
Date last accuracy tested -7- (2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy