2013_0510 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE -'\-,
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: > G % S X /
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.
C
i;
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Serial Number (� � f � �
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At - � 'c' . �'. C /< /L e P-k- 0 v(- Z, G,A
The above is certified to be true.
Firm Name I e AP kL- I i 91`
Firm Address 1'90156'L % ? 7 i4,1417,
TX
Gauge # 06e y / 7 r O
Date last accuracy tested
Certified Testers ��- l"lr�
Cert. Tester No. �� v biz R Date - r'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed ,
Tight ,?
Closed Tight X
Leaked ❑
Opened at
vsid
Opened at
osid
osid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name I e AP kL- I i 91`
Firm Address 1'90156'L % ? 7 i4,1417,
TX
Gauge # 06e y / 7 r O
Date last accuracy tested
Certified Testers ��- l"lr�
Cert. Tester No. �� v biz R Date - r'
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy