2014_0128CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: t (l G �C GO P 1Q C i
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 W t i.-1/�
Model Number ) O
Serial Number 5 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
;sl�•r
Size
Located At 1 ke-W ► t y� co rQ"��+
The above is certified to be true.
C
Firm Name t� ►'1 CS (3 oc VS L&q Certified Tester �' ► "� � �
Firm Address y 3 6wpas QG. Guy j, ,kct Tester No. ` Q DO t Date a$
I 603(p
Gauge # .) 90 41 Qii k(Ns 1— - S
Date Last accuracy tested - 3 0 '
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
f Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
agaTight
r
o
RP -_ Dsid
Leaked ❑
osid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
%�o(�G
N o n ce
M��
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
C
Firm Name t� ►'1 CS (3 oc VS L&q Certified Tester �' ► "� � �
Firm Address y 3 6wpas QG. Guy j, ,kct Tester No. ` Q DO t Date a$
I 603(p
Gauge # .) 90 41 Qii k(Ns 1— - S
Date Last accuracy tested - 3 0 '
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy