2013_0211CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE�_
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: I ±u f � S .17 lv L '
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 ttl � j r f
Model Number - 7 y
Serial Number le /'
TYPE OF ASSEMBLY
❑ Pressure Vacumn Breaker
o Atmosphere Vacuum Breaker
c
Size
Located At (/°ei� l /;AA f /- el, 14 y FX 0 At
S t KI-e1,
The above is certified to be true.
Firm Name Ca w l % r t
Firm Address �v' 0y 7 a tylT X",q
Gauge # ,-Zey/ 7 f V
Date last accuracy tested - /'z
Certified Tester
Cent Tester No d WO Date '� - 1':F
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 3°
Tight 15
Closed Tight 2(
Leaked
Opened at
sid
Opened at
osid
paid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
_,_ —Dsid
_______v sid
RP sid
The above is certified to be true.
Firm Name Ca w l % r t
Firm Address �v' 0y 7 a tylT X",q
Gauge # ,-Zey/ 7 f V
Date last accuracy tested - /'z
Certified Tester
Cent Tester No d WO Date '� - 1':F
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy