2013_0510 (3)CIIECK ONE:
IRRIGATION DOMESTIC - -4, ` FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: G% I /c�Ur i� ✓�'
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
Manufacturer
Model Number
TYPE OF ASSEMBLY
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
4'1 lq- / Size `°)
e) G` % -, Located At Z,(
Serial Number Y
The above is certified to be true.
Firm Name %yc j C)(-- %� ✓�
Firm Address I 7i,7 &I J f
Gauge # e, LSO C/ l ? "l C
Certified Tester
Cert. Tester No. Pr6f'66-C, lc?-2- Date
Date last accuracy tested 0 `l - S /,,5;y
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 �'
Tight �6
Closed Tight N�'
Leaked / �� ❑
Opened at
osid
Opened at
oSid
osid
RP -._ _-psid
Leaked o
Did not Open o
Leaked a
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight a
Opened at
oSid
Opened at
oSid
___p sid
RP sid
The above is certified to be true.
Firm Name %yc j C)(-- %� ✓�
Firm Address I 7i,7 &I J f
Gauge # e, LSO C/ l ? "l C
Certified Tester
Cert. Tester No. Pr6f'66-C, lc?-2- Date
Date last accuracy tested 0 `l - S /,,5;y
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy