2014_0221CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
Q
LOCATION OF SERVICE: < t� n 1
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.
C / Reduced Pressure Principle
Double Check Valve
Manufacturer } 1 l y \\ i\5
Model Number o
Serial Number'
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size ` q
Located At�ict'Clr'�
The above is certified to be true.
Firm Name c�,.C, � l a.G(A�(0 w, Certified Tester U,7, -V \ A n (1� f S
Firm Address �' �' 0 w -e r. Cho Cat Tester No. 'j
rJ
Gauge # E� u Q �5 z-� q .' �
Date last accuracy tested r
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` Y�
Opened at
Opened at
nSid
Tight 41
RP -_psid
Leaked ❑
nSid
nSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
N
k
Materials
C)
� \�..
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 c�,.C, � l a.G(A�(0 w, Certified Tester U,7, -V \ A n (1� f S
Firm Address �' �' 0 w -e r. Cho Cat Tester No. 'j
rJ
Gauge # E� u Q �5 z-� q .' �
Date last accuracy tested r
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy