2014_0201 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
4
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker"
Manufacturer Q� `� Size 3)9
Model Number `" 1 T. Located At B a r J.-.0, 6• t'-)n IV c o 44
Side OF6u► d►„q in Ii-
Serial Number t �0 40d &-ma joT
The above is certified to be true.
Firm Name
Firm Address .-7 ! ! �' `�' h`
Gauge #
Date last accuracy tested
Certified Tester da # Al e R 7/"
Cert. Tester No. 13 9 /?" f Date ' l s l � 4,1
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
Tif ❑
1' i
Leaked ❑
nsid
nsid
RP- psid
Leaked ❑
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
Firm Address .-7 ! ! �' `�' h`
Gauge #
Date last accuracy tested
Certified Tester da # Al e R 7/"
Cert. Tester No. 13 9 /?" f Date ' l s l � 4,1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy