2013_1125 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
-//t/ W
The backaow previcaton assembly detailed below has been tested and mamtamed as required by TNRCC
mplations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle 0 Pressure Vacuum Breaker
,Z' Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer zAt - —k"�4 size 211
Model Number *' Z 04, � 1 - Located At Al, W,
Serial Number / S- Z- L;' 2 "
White - Customer's Copy Yellow - city copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAAKER.
Double Check Val" Assembly
1st Check
tad Check 2.O
ReWvalve
Air Inlet
Check Valve
Initial Test
DC-Closed
Tight I-z",
Closed Tight -Cr
Leaked
Opened at
sid
Opened at
-jusid
—j)sid
RP -_,, -.psid
Leaked C
Did not Open C3
Leaked C3
Repairs
and
Materials
Used
Test After
L
DC-Closed
Closed Tight a
Opened at
opened at
-.psid
I:ft
Rcqpxir
Tight
--psid
sid
R?
The above is cerfified to be am.
Firm Nam &L• Loa- Certified Tester
Firm Address e v 5 c-14 '71 -7 cut Tester No. gjovv- 6 t,,- r7 Dam
Gauge # P!2 0
Date last accuracy tested 6, 13
White - Customer's Copy Yellow - city copy Pink - Tester's Copy