2014_0103 (2)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BA=OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: t 4110 .�` . 4 aL, / " A
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
r- Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve c Atmosphere Vacuum Breaker
Manufacturer LJ " -W-5 Size
Model Number -7()-7 /'1
Serial Number
Located At LIJ I
The above is certified to be true.
Firm
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm
Address —,q411 Nl; a/. ,ar —7Lti A!-7
Cert. Tester No.
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight y ❑
RP- L • I' psid
Leaked ❑
Leaked ❑
7
psid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
psid
RP sid
The above is certified to be true.
Firm
Name ,;4.
Certified Tester��.••
Firm
Address —,q411 Nl; a/. ,ar —7Lti A!-7
Cert. Tester No.
�j�_'r7`'�`%
Gauge # (:27r771 G.9` .:
Date Last accuracy tested -,711
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy