2014_0323CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: % &6? / �S , 6,e i � l /y i
The backflow 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
,2" Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer rt/j4, t't'S Size ;
Model Number 02 L G 1L IQ' Located At N,
Serial Number h I S- 3
The above is certified to be true.
Firm Name --- 111�� CertiSed Tester►' ,-)
Firm Address ,, l E.r, u f r Cert. Tester No. S S 7, Date 3 - z -3 -/�
Gauge #/G 2 Z
Date last accuracy tested
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 Cheri:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 2f
Opened at
Opened at
osid
Tight
Leaked / ❑
paid
_psid
RP- _,psid
Leaked o
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-------- psid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name --- 111�� CertiSed Tester►' ,-)
Firm Address ,, l E.r, u f r Cert. Tester No. S S 7, Date 3 - z -3 -/�
Gauge #/G 2 Z
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy