2013_0729CHECK ONE:
IRRIGATION DOMESTIC L"/ FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 5,41 z s
V
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C r Reduced Pressure Principle
� Double Check Valve
Manufacturer 1A/ 141,
Model Number
5.5-0
Serial Number y/ /6,176,01
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size
Z
Located At . - elf
The above is certified to be true.
Firm Name A r* -- (yal Certified Testes X x ,'+41, Ct°
Firm Address C-21 t' V- 79-7 Cert. Tester No- Onm4 L2-Date 7
Gauge # Q % a Q 8
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
Relief Valve
Air Inlet
Check Valve
1st Check Z
2nd Check Z, °
Initial Test
DC- Closed
Tight
closed Tight
Leaked 0
Opened at
osid
Opened at
osid
osid
RP- ._.psid
Leaked p
Did not Open 0
Leaked 0
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight 0
Opened at
osid
Opened at
osid
_nsid
RP sid
The above is certified to be true.
Firm Name A r* -- (yal Certified Testes X x ,'+41, Ct°
Firm Address C-21 t' V- 79-7 Cert. Tester No- Onm4 L2-Date 7
Gauge # Q % a Q 8
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy