2013_0927CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE V
BACSFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: On tuem I arijerny. 1001 E_ Sandy Inke, Cowell Zt 7S0 1c1
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
V Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer (IrneS Size
Model Number - W —A - «r- Located At R►Cer Rybrn 13
Serial Number Fl -0085
The above is certified to be true.
Firm Name rreL[,_Sni,4k6znet;eCA
r
Firm Address olfsd 1 U Eu IeSc AI JO F1,105
TX 700
Gauge # 0110331
Date last accuracy tested 3-5-1-3
Certified Tester . im l Lr s
Cart. Tester No. Aft ly7'Fs Date __'4-4/E 7 l3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
r�sS
DC- Closed
Tight
RP- II vsid
Lc6;� ❑
Closed Tight GK
Leaked 3:3 ❑
Opened at
nSid
Opened at
vSid
Did not Open o
vSid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
vSid
Opened at
vSid
_vsid
RP sid
The above is certified to be true.
Firm Name rreL[,_Sni,4k6znet;eCA
r
Firm Address olfsd 1 U Eu IeSc AI JO F1,105
TX 700
Gauge # 0110331
Date last accuracy tested 3-5-1-3
Certified Tester . im l Lr s
Cart. Tester No. Aft ly7'Fs Date __'4-4/E 7 l3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy