2013_0628 (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 4 lO(2 S PI. A %
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 ❑ Pressure Vacuum Breaker
tee'' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer � a.• -��--5 Size
Model Number 00'7 Af -I--- Located At .� r : n 4r'
Serial Number
The above is certifiers to be true.
Firm Name A:4-V
Certified Tester 614tL 4t),1 lieg" I
Firm Address • " 1 Cart Tester No. .l n ' ?0 Date A", /3
W,,,� 4 � k � ,-e) � � (- 0
Gauge # 0k Q-( j Jj
Date last accuracy tested
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
Leaked ❑
nsid
psid
RP - � sid
z. 0
Leaked ❑
—
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
psid
osid
RP sid
1
11
The above is certifiers to be true.
Firm Name A:4-V
Certified Tester 614tL 4t),1 lieg" I
Firm Address • " 1 Cart Tester No. .l n ' ?0 Date A", /3
W,,,� 4 � k � ,-e) � � (- 0
Gauge # 0k Q-( j Jj
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy