2013_1125CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
te
LOCATION OF SERVICE: qq L S'.e(
The bacldlow 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 C Pressure Vacuum Breaker
pZ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer &IM.L2 &I . size ;
Model Number Located At Al. W, LlA
Serial Number 17 4 o,7 0,? I
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 3, 0
Initial Test
DC- Closed
Tight of
Closed Tight
Leaked
+t'
C
Opened at
nsid
Opened at
_ d
- id
RP -_--- psid
�d C
Did not Open D
Leaked C
Repairs
and
Materials
Used
Test ARer
DC- Closed Closed Tight
C Opened at
Opened at nsid
Repair
Tight C
id
osid
RP
The above is certified to be true.
Firm Name Aar,,
. Lite
Catified Tester A hyyAjll
Firm Address
Ica " `7 1� 7
Cat. Tester No. Wo •mil � � 7 Date
Gauge # U ; v �i vk{- Y -f
Date last accuracy tested 6-11,13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy