2013_0104 (16)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: a� k: ►c 1 107-
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.
Reduced Pressure Principle
C Double Check Valve
Manufacturer LA, , fl
Model Number IOcl 12T
Serial Number A `I Q In 3LJ
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
t
Size
Located At A -Ly -w e � J;
The above is certifie
dt� d tto— A be true. --�-- /
Firm Name � � �: i r l c j e c i" n n Certified Tesw A.
Firm Address ,�31a3 MQ,,; R # &X� Cert. Tester No. 6RX)I3S71S Date 11Q1,D0
Gauge # DcI I
Date last accuracy tested
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 ❑
Closed Tight C
Leaked ❑
Opened at
nsid
Opened at
nSid
nSid
RP- -7. Y Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nSid
DSid
RP sid
The above is certifie
dt� d tto— A be true. --�-- /
Firm Name � � �: i r l c j e c i" n n Certified Tesw A.
Firm Address ,�31a3 MQ,,; R # &X� Cert. Tester No. 6RX)I3S71S Date 11Q1,D0
Gauge # DcI I
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy