2014_0313CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /2-, p(9 ' 1
The baclflow 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
t
Model Number
serial Number } C LIZ
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size y
Located At
The above is certified to be true.
Firm Name
A udp Rp
v el
Firm Address 3q(), C L� Iy�.
Gauge #
6-Akjjg A e
certified Tester JV _
Cert. Testa No. ROW 31 S1 Date 5^ i.3— 1
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 ❑
Dsid
osid
RP7,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Name
A udp Rp
v el
Firm Address 3q(), C L� Iy�.
Gauge #
6-Akjjg A e
certified Tester JV _
Cert. Testa No. ROW 31 S1 Date 5^ i.3— 1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy