2014_0128CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACEILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �, V i ac;\ G-a ,
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 ❑ Pressure Vacuum Breaker
Nr" Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer � �A l + \ C, Size /Zi
Model Number
350 Located At (0 S I ke—N,W(K\J �f owe
Serial Number
�C3 a� y bo Y"\ t2ff�,�-
The above is certified to be true.
Firm Name PV IlOI .t V ����)W Certified Testa 1. L
Firm Address y 3 O w Q _nS o Cat. Testa No. �0 00 514 Date
Tx jW-, -
Gauge # 06 U ` "
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 v
Opened at
Opened at
usid
Tight ❑
Leaked ❑
psid
usid
ilagl ��
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
^,
and
a f�Q.
f V 0 fN E;
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
usid
Repair
Tight ❑
nsid
usid
RP sid
The above is certified to be true.
Firm Name PV IlOI .t V ����)W Certified Testa 1. L
Firm Address y 3 O w Q _nS o Cat. Testa No. �0 00 514 Date
Tx jW-, -
Gauge # 06 U ` "
Date last accuracy tested -"{
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy