2014_0323 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bacl&ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
.21 Double Check Valve
Manufacturer
Model Number 642
Serial Number � ef)
TYPE OF ASSEMBLY
Cl Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located Atr�`
The above is certified to be true.
l
Firm Name ���,� z6Y49e,,/CertifiedTester
Firm Address S/ ? C)CL -144kd Jr Cert. Testa No. ��"�t�X.S� Date _ -3-2 -3
Gauge # /,"J10 2-z z 4(4
Date last accuracy tested —L-L-2 :2
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 Z
Opened at
Opened at
nsid
Tight 0
,R'_ Lt psid
Leaked a
Leaked o
!'
nsid
nsid
Did not Open o
Leaked a
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
______.p sid
Repair
Tight a
psid
psid
RP sid
The above is certified to be true.
l
Firm Name ���,� z6Y49e,,/CertifiedTester
Firm Address S/ ? C)CL -144kd Jr Cert. Testa No. ��"�t�X.S� Date _ -3-2 -3
Gauge # /,"J10 2-z z 4(4
Date last accuracy tested —L-L-2 :2
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy