2013_0927 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACI FLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1In1uer--G10r- &de^V, 1001L Sindi/.U,2 1 a 71019
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 C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Clmes Size
Model Number t^ nll 13F" Located At , Ser Rap," A
Serial Number P:()307
The above is certified to be true.
Firm Name FreLJ Sg,4gQ nerlurA
Firm Address ,4aA l L). 6-165 X31 ,J1 F -1 ias
TX ?�Oqo
Gauge # 1a 11 D3 51
Date last accuracy tested 3-5-13
Certified Tester Jw /his
Cent Tester No. Q p(,'Y) 1 q /i" 5 Date — 7
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 Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 12'
Opened at
Opened at
nsid
Tight
Leaked ❑
nsid
nsid
a
RP- .` sid
Leaked ❑
y,H
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight Cl
psid
nsid
RP sid
The above is certified to be true.
Firm Name FreLJ Sg,4gQ nerlurA
Firm Address ,4aA l L). 6-165 X31 ,J1 F -1 ias
TX ?�Oqo
Gauge # 1a 11 D3 51
Date last accuracy tested 3-5-13
Certified Tester Jw /his
Cent Tester No. Q p(,'Y) 1 q /i" 5 Date — 7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy