2013_0927 (5)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 11ni uerSra 1 CcC�,lem y . IC01 E 2 CSalle. � // TX 25-0 14
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
a,— Double Check Valve Ct Atmosphere Vacuum Breaker
Manufacturer rim e S Size
Model Number 3%IC, - BF Located At R1 sel, 209t"
Serial Number FH- J30k
The above is certified to be true.
Firm Name F, r L.1, Sa ItI Y Orn &Ice.
Firm Address aka 1 W. &16S &&L155
L155
7-X 7('0910
Gauge # 1,21103 51
Date last accuracy tested 3-S-13
Certified Tester .6Q ha►ra s
Cert. Tester No. MC0114 2�U Date 7 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 ce
Opened at
Opened at
osid
SS
Tight
R.P -�psid
Leaked ❑
Leaked 3.7 ❑
psid
osid
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
____—.p sid
Repair
Tight Cl
osid
RP sid
The above is certified to be true.
Firm Name F, r L.1, Sa ItI Y Orn &Ice.
Firm Address aka 1 W. &16S &&L155
L155
7-X 7('0910
Gauge # 1,21103 51
Date last accuracy tested 3-S-13
Certified Tester .6Q ha►ra s
Cert. Tester No. MC0114 2�U Date 7 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy