2013_0927 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ✓
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: I iwy rs4I Qcrn emY , /00/ E..Scrr /dL�l1�� CaA�e // TX 25611
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
3"' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 6ML-6 Size Y7
Model Number o2=A M 3
Serial Number 034saa
... �!��
The above is certified to be true.
Firm Name Fret A� h� ai ;,
Firm Addrew,.99Al U, 6.165 Id Ar-
Ty 7(,040
Gauge # gno3Sf
Date last accuracy tested LLD
D
Certified Tester In Il w.5
Cert. Tester No. AP00147 ,75 Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
RP -, '�- psid
Leaked GK
Leaked �
Dsid
osid
Did not Open ❑
Leaked ❑
Repairs
and
veods -4 1
CheckWue rq&ed
,Deeds 0 a
ChPtkt, 4e rrAeed
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name Fret A� h� ai ;,
Firm Addrew,.99Al U, 6.165 Id Ar-
Ty 7(,040
Gauge # gno3Sf
Date last accuracy tested LLD
D
Certified Tester In Il w.5
Cert. Tester No. AP00147 ,75 Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy