2014_0201CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bacldlow 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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer W Q `F l S Size %D
Model Number =1 1 D C _D
Serial Number ' " 5/1-5008
Located At Aloo r ED, CI o n
or 6 v) ►ni in 1, I�
The above is certified to be true.
Firm NameBA --,TFXIS
Firm Address 75 ) D � s _A,.L �o ni,
Gauge #
Date last accuracy tested
T
(�R
Certified Tester V �7 . ✓ � L
Cert. Testa No. F: r/ )/ 'T 1 r t 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
Closed Tight ❑
Opened at
Opened at
osid
Tight ❑
RP- sid
Leaked ❑
Leaked ❑
? ,
osid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm NameBA --,TFXIS
Firm Address 75 ) D � s _A,.L �o ni,
Gauge #
Date last accuracy tested
T
(�R
Certified Tester V �7 . ✓ � L
Cert. Testa No. F: r/ )/ 'T 1 r t Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy