2013_1125 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `/ Y"z-f- . W,
The backflow 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 a Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturertrty Size
Model Number �-r-v Located At Al. V-� ea (-Z Mks,—
Serial Number R 185- 2
The above is certified to be true. n
c' n ntz
Firm Name XcZ� Low VI L Ceriifiod Testa ,�
Firm Addness -7--j-7 Cent. Tester No.T PD -.n 6r`S `7 Dam % t - Zs 13
oyc .
To--, 7.5 I U d
Gauge # U ? o rfv 4-p Z
Date last accuracy tested 6 -1 It - ' 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
a
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Doable Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
lst Check
2nd Check A //
Initial Test
DC- Closed
Tight �.
Closed Tight
Leaked
Opened at
sid
Opened at
_psid
_ —paid
RP-_--paid
Leaked C
Did not Open C
Lmkod !�
Repairs
and
Materials
Used
;es t After
epair
DC- Closed
Tight C
Closed Tight C
Opened at
_,paid
Opened at
—.p sid
sid
RP
The above is certified to be true. n
c' n ntz
Firm Name XcZ� Low VI L Ceriifiod Testa ,�
Firm Addness -7--j-7 Cent. Tester No.T PD -.n 6r`S `7 Dam % t - Zs 13
oyc .
To--, 7.5 I U d
Gauge # U ? o rfv 4-p Z
Date last accuracy tested 6 -1 It - ' 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
a