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2013_1105CHECK ONE: IRRIGATION_ DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF COPPELL LOCATION OF SERVICE: 558 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 C Pressure Vacuum Breaker i Double Check Valve 0 Atmosphere Vacuum Breaker Manufacturer Model Number FN;3r0 9M Serial Number �- `j Size 1r Located At V-3-", The above is certified to be true. Firm Name 1J��'� Certified Testa Firm Address © - Cert. Testa No. `'�3 Date - S -o Gauge # " 11D1(-)4c0l Date last accuracy tested X- q - 1 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 Tight q(- RP -_psid Closed Tight 9E Leaked o Opened at vsid Opened at vsid vsid Leaked p Did not Open o Leaked o Reps and Materials Used Test After DC- Closed Closed Tight o Opened at Opened at _osid Repair Tight o psid vsid RP sid The above is certified to be true. Firm Name 1J��'� Certified Testa Firm Address © - Cert. Testa No. `'�3 Date - S -o Gauge # " 11D1(-)4c0l Date last accuracy tested X- q - 1 7�, White - Customer's Copy Yellow - City Copy Pink - Tester's Copy