2013_0927 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: j In i uersa I (AxAem y. loot E &,dy Lake, C,.well TX 75019
The backflow 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
2✓ Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer CrneS Size ;y1e1
Model Number 907n8 171 Located At R, sel,
Serial Number 661 01-5
The above is certified to be true.
Firm Name r« Lie Sa" Qme.�
Firm Address IRa I Q, Q65 �1 1
Tx 7 &oqo
Gauge # la 110331
Date last accuracy tested 3 - E -13
Certified Tester . len /heyng s
Cat Taster No. 8Pa,�l1l 713 Date 4 a 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 Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
Leaked o
osid
osid
Fa,
RP- t7.O psid
Lea ;J� ❑
0,0
Did not Open o
Leaked C3
Repairs
and
Materials
_
k),0445 4.je(.fraj
valut,bewase if
C «ck ed
1t 11
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
sid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name r« Lie Sa" Qme.�
Firm Address IRa I Q, Q65 �1 1
Tx 7 &oqo
Gauge # la 110331
Date last accuracy tested 3 - E -13
Certified Tester . len /heyng s
Cat Taster No. 8Pa,�l1l 713 Date 4 a 7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy