2014_0423 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 3-71 S. two V A I L n-
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.
TYPE OF ASSEMBLY
❑/ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
�7 Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer + `�' `_-� Size d r+
Model Number ,707 M Located At 1 r-, � .c -r.4 l� • Il'�(i °l—r
Serial Number .:;t 0 7 L27
The above is certified to be true.
Firm Name,; �� /i_�l l C �C-�1 t3[� 1� 1C Certified Tester
Firm Address t' Cert. Tester No. 'R) ' !,Date
W t ,V i to 75
Gauge # OF I)) (2Fj9
Date last accuracy tested —_� — / 14
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 ❑
Opened at
oSid
Opened at
oSid
oSid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
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,; �� /i_�l l C �C-�1 t3[� 1� 1C Certified Tester
Firm Address t' Cert. Tester No. 'R) ' !,Date
W t ,V i to 75
Gauge # OF I)) (2Fj9
Date last accuracy tested —_� — / 14
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy