2013_0415 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ."
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 511-f
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer 161 /L o
Model Number < y
Serial Number DU 2-q
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At (�- llhuW gn
I
The above is cerdfieed to be true.
Firm N �'� , 'c Certified Tester ;)Z -
Firm A Air- /4D � 1 Cat. Tester No. LM H Date
74P�
Gauge # P&OIII& � f
Date last accuracy tested I2 - "/l -/t-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
Zed Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight e
Opened at
Opened at
osid
Tight -;' - I
RP -_psid
Leaked ❑
Leaked ❑
1�z - Ce
psid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
C- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
ght ❑
ERP
asid
osid
sid
The above is cerdfieed to be true.
Firm N �'� , 'c Certified Tester ;)Z -
Firm A Air- /4D � 1 Cat. Tester No. LM H Date
74P�
Gauge # P&OIII& � f
Date last accuracy tested I2 - "/l -/t-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy