2014_0201 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: C mT r I NFP.
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.
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
^_ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer a }S Size
Model Number d C 7 A4 1 Q7- Located At .5& DF
f5 / q s f
Serial Number u ! _ D NC Pifi
The above is certified to be true.
Firm Name &L s5t ti/5 iUG,
Certified Tester J(l/1"/ 4, 7'/ Z,—
Firm Address 75/ IC944S � g4rhna i i 4r Cert. Testa No. IP 0 013 I DD Date
Gauge # 6 12-3 V6 I
Date last accuracy tested
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
Tight ❑
RP -J— Lpsid
Leaked ❑
nsid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name &L s5t ti/5 iUG,
Certified Tester J(l/1"/ 4, 7'/ Z,—
Firm Address 75/ IC944S � g4rhna i i 4r Cert. Testa No. IP 0 013 I DD Date
Gauge # 6 12-3 V6 I
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy