2013_0104 (19)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: u; k I isiit of -� a 1 �e #�
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
❑ Double Check Valve
Manufacturer 1t , A, -,
Model Number GK/'1 M Q L.
Serial Number A 3S LPS 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At _ Pul wl, L
The above is certified to be true.
Firm Name )1;ed4 ;.e ir_lEc!'vr+
Firm Address Q--�U /- Ir : (+ tl ;a 3c L
Gauge # C) c) J C)
Date last accuracy tested 3 o
Certified Tester
Cert. Tester No. Date 3
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
nsid
Tight ❑
R.P - -7. 9 sid
Leaked ❑
nsid
nsid
Leaked p
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name )1;ed4 ;.e ir_lEc!'vr+
Firm Address Q--�U /- Ir : (+ tl ;a 3c L
Gauge # C) c) J C)
Date last accuracy tested 3 o
Certified Tester
Cert. Tester No. Date 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy