2014_0423 (4)CHECK 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 Cam' R n .,/ 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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer - � t � A + -� S Size F)
Model Number 7 7 b C bb - (xV Located At Tr-, \/ A U 3rn e Y'
Serial Number N k 309
The above is certified to be true.
Firm Name i nfl'AAC k-t' %1 ._.l.r x Certified Tester
Firm Address �, .. Cat Tester No. 4PnncL-
IL e w; v; ile, -"F) C 7
Gauge # O �- Y) [�
Date last accuracy tested a —5 -) � 1
v
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
Ininal Test
DC- Closed
Tight in
Closed Tight ❑
Leaked ❑
Opened at
nsid
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 nfl'AAC k-t' %1 ._.l.r x Certified Tester
Firm Address �, .. Cat Tester No. 4PnncL-
IL e w; v; ile, -"F) C 7
Gauge # O �- Y) [�
Date last accuracy tested a —5 -) � 1
v
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy