2014_0423CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 3.71 S. Bnv A) La,
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 A +
Model Number 0 O 7 M's
Serial Number .,� () 7L A
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
fr
Size 1
Located At --In \/ A t 1 it ti), cn f nee
The above is certified to be true.
Firm Name r, Certified Tester _'� +&,j
Firm Address Cert. Tester No. '.P 7nJ Date 1
X i
Gauge # nq-, 10- 11., T �C,
Date last accuracy tested 4 yl
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
Tight ❑
Closed Tight ❑
Leaked Cl
Opened at
osid
Opened at
osid
osid
RP- ._,_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name r, Certified Tester _'� +&,j
Firm Address Cert. Tester No. '.P 7nJ Date 1
X i
Gauge # nq-, 10- 11., T �C,
Date last accuracy tested 4 yl
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy