2014_0221CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 7c 1 `" 2 M\0 ('
The bacifflow 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
Model Number
Serial Number 0 �5
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At - W n,. � A (-DrV\ (''1OW
The above is certified to be true.
Firm Name 006,e, -S Certified Tester �0r- V A f�•, -
Firm Address 0 t 3 0 w1 C A'�) Cert. Tester No. & 0 0619 1,YDate
Gauge #'J�(' r!�a�i�003(0
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 "
Opened at
Opened at
osid
Tight ❑
Leaked ❑
osid
nsid
RP psid
Leaked C
Did not Open ❑
Leaked ❑
Repairs
i'\?—.
C7) i'\?—.
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name 006,e, -S Certified Tester �0r- V A f�•, -
Firm Address 0 t 3 0 w1 C A'�) Cert. Tester No. & 0 0619 1,YDate
Gauge #'J�(' r!�a�i�003(0
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy