2014_0103 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: / 4
The back -low 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
C Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At R� �► �` r
Serial Number
The above is certified to be true.
Firm Name p. S /; f : r� i Certified Tester
Firm Address -_r f' -7t- Cert. Test= No. i4cq'2Date L
Gauge # :? -?
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
o�
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check:
2nd Check:
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
nsid
nsid
RP -_psid
Leaked C
Did not Open C
Leaked ❑
Repairs
and
L"4et-
e j,4a�
on
e c-i yl
Materials
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name p. S /; f : r� i Certified Tester
Firm Address -_r f' -7t- Cert. Test= No. i4cq'2Date L
Gauge # :? -?
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy