2013_0104 (20)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 0. ; f k T; p k ; I,-! :.,, IO2S S. r) 3c'�
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 1. 141
Model Number CLn /Yl 01 Cx
Serial Number A i I
TYPE OF ASSEMBLY
12 Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size �� It
Located At &� Vitj
The above is certified to be true..
A
Firm Name l'isd -T e
1 t'roi l r- Lo—
Firm Address 2`&t ?. fqr If # 4'U
TV -75tt I I
Gauge # Oc, I( - �ufjU
Date last accuracy tested Z 4 ) .; ,�
Certified Tester T -e , /Y - l
Cat Tester No. RP(w►a S 7S` Date < . -}
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 ❑
RP -, 9, G DSid
Closed Tight ❑
Leaked ❑
Opened at
a, psid
Opened at
oSid
oSid
Leaked o
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true..
A
Firm Name l'isd -T e
1 t'roi l r- Lo—
Firm Address 2`&t ?. fqr If # 4'U
TV -75tt I I
Gauge # Oc, I( - �ufjU
Date last accuracy tested Z 4 ) .; ,�
Certified Tester T -e , /Y - l
Cat Tester No. RP(w►a S 7S` Date < . -}
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy