2013_0628 (5)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
H
LOCATION OF SERVICE: b nO
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
e2' Double Check Valve ❑ Atmosphere Vacuum Breaker
i) p * °r
Manufacturer 1A %�"!ihs Size U
Model Number -76)'ef Located At W
Serial Number i �1 A 8 I
The above is certified to be true.
Firm Name ?' ''�1�n�-r
Firm Address P
Gauge #
Date last accuracy tested lj '
Certified Tester ,At ,�- 0.114. *.ti S
Cent. Testa No. kp' d b . , Date 6 --�cq- l_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 X
Opened at
Opened at
nsid
Tight
RP- '� sid
Leaked ❑
Leaked ❑
-
psid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Auer
DC- Closed
Closed Tight o
Opened at
Opened at
_ osid
Repair
Tight ❑
psid
vsid
RP sid
The above is certified to be true.
Firm Name ?' ''�1�n�-r
Firm Address P
Gauge #
Date last accuracy tested lj '
Certified Tester ,At ,�- 0.114. *.ti S
Cent. Testa No. kp' d b . , Date 6 --�cq- l_3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy