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2014_0201 (3)
CIIECK ONE: IRRIGATION DOMESTIC FIRELINE BACKILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: t7rft , �N7A�N�v 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 ❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker ❑ Double Check Valve 1: Atmosphere Vacuum Breaker tur Manufacer 0, Size ` Model Number 00 7 M 1 0 Located At kf o r .0 • ba WA :� td e of � v► � Ong N�Qr ►�. Serial Number / J, (2, C 3 9 The above is certified to be true. Firm Name C Certified Tester ' ° 4,� -r z Firm Address r9 +h+ tqr Ii nalon 4 • Cert. Tester No. I?) PON3 I (Y�� Date Gauge # Date last accuracy tested r l - ©"% .&nA& 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 psid 1J¢i Tight ❑ RP- I. `7 osid Leaked ❑ osid nsid S S Leaked ❑ Did not Open ❑ Leaked ❑ Reps and Materials Used Test After DC- Closed Closed Tight ❑ Opened at Opened at nsid Repair Tight ❑ nsid osid RP sid The above is certified to be true. Firm Name C Certified Tester ' ° 4,� -r z Firm Address r9 +h+ tqr Ii nalon 4 • Cert. Tester No. I?) PON3 I (Y�� Date Gauge # Date last accuracy tested r l - ©"% .&nA& White - Customer's Copy Yellow - City Copy Pink - Tester's Copy