2014_0103CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: / �l
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 C Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer c. ' P < Size Z - 0
Model Number Q Q :2 MI Located At % �x
Serial Number
The above is certified to be true.
Firm Name l . Certified Tester ��,�•�
Firm Address -74-11" Cert. Tester No. rap cpn 14 ce4 pate
Gauge # Lp -7 t2 -i's
Date last accuracy tested , M // 7
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 ❑
oSid
oSid
RP- /. DSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name l . Certified Tester ��,�•�
Firm Address -74-11" Cert. Tester No. rap cpn 14 ce4 pate
Gauge # Lp -7 t2 -i's
Date last accuracy tested , M // 7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy