2013_0104 (17)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACEFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: a, k I. , lo-?-,T
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
C Double Check Valve
Manufacturer'
Model Number ^ -C, rn Q 0 T
Serial A
Number Q -s� 19
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size I %a't
Located At �� O a L,,c.11f, .<<t.e.5
The above is certified to be true.
Firm Name A 11 a d 4
Firm Address Q ,� #3a&
Tk -750111
Gauge # 09 l D o) U b U
Date last accuracy tested 3 /1 „l O/
Certified Tester JUn�, /'i. e ,r 4,
Cent. Tester No. R kQ 1 a s ?s Date 1 ! avl3
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 M
Opened at
Opened at
oSid
Tight C
1Z -_&LLpsid
Leaked o
Leaked o
= • Ur, nsid
oSid
Did not Open o
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nSid
Repair
Tight 0
nSid
osid
RP Sid
The above is certified to be true.
Firm Name A 11 a d 4
Firm Address Q ,� #3a&
Tk -750111
Gauge # 09 l D o) U b U
Date last accuracy tested 3 /1 „l O/
Certified Tester JUn�, /'i. e ,r 4,
Cent. Tester No. R kQ 1 a s ?s Date 1 ! avl3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy