2014_0313CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAC'KFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: � n 1 \() (0 �
The bac0ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer 4 60
Model Number
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At f y r
The above is certified to be true.
Firm Name 6�'1� A e 1(\ 4n-
Firm Address 3 0 GO PIV '— Dn
Gauge # 6 �`
Date last accuracy tested
Certified Tester
Cert. Tester No. 6 C' r-T % Date 3 I t
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 e
RP- , -,psid
Leaked ❑
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test ABer
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 6�'1� A e 1(\ 4n-
Firm Address 3 0 GO PIV '— Dn
Gauge # 6 �`
Date last accuracy tested
Certified Tester
Cert. Tester No. 6 C' r-T % Date 3 I t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy