2014_0103 (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: .5` X111
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 C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer ''�� %� -At , Size 1,
Model Number «Z� 7 A-1 i Located At
Scrial Number zl ;T 414, .V
The above is certified to be true.
Firm Name
Firm Address --,?41
Gauge #
Date last accuracy tested
Certified Tester 5�..
Cent. Tester No. -;,, r Date
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 C
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
Firm Address --,?41
Gauge #
Date last accuracy tested
Certified Tester 5�..
Cent. Tester No. -;,, r Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy