2014_0128CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ?7 O G '. Cc, " -,kl.1 l
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
V Double Check Valve
Manufacturer W-%
Model Number 0
ffl\sSerial Number L -
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name B nX .V ��Ik W Certified Tester k\\r e 's
Firm Address � 1 `) 0 We .ttS QV . GC�w�ac � Cert. Tester No. Date
- T'K-?G0310
Gauge # 'I_-) ()'K2ZN
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
I
1st Check:
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight`''
Opened at
Opened at
oSid
❑
Leaked ❑
oSid
oSid
o�g1Tight
1 4
RP - -- Sid
Lea. ed C
Did not Op en ❑
ed
Leak ❑
Reps
and
Materials
e�,
6f-\ 1z-►
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
osid
Repair
Tight ❑
tssid
oSid
RP sid
The above is certified to be true.
Firm Name B nX .V ��Ik W Certified Tester k\\r e 's
Firm Address � 1 `) 0 We .ttS QV . GC�w�ac � Cert. Tester No. Date
- T'K-?G0310
Gauge # 'I_-) ()'K2ZN
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy