2014_0322CIIECK ONE:
IRRIGATION /` DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: f 41 X / 5, 8 l�l� ll
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer &/d k, I 5
Model Number 6C) -7
Serial Number ;l q
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size
Located At l-1 '
The above is certified to be true.
Firm Name -'-'4k-1 - /z", Certified Tester
Firm Address ,� 5 1 23, R C, r i Aa r i Cent. Testa NoM6b ' S `" 3 Date z
Gauge # d l/) 2 Z Z V&
Date last accuracy tested Z
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 ,;'
Opened at
Opened at
nSid
E Rf
Sid
Leaked ❑
/
nsid
nsid
d ❑"
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Sid
Repair
Tight ❑
nsid
nSid
IL
RP Sid
The above is certified to be true.
Firm Name -'-'4k-1 - /z", Certified Tester
Firm Address ,� 5 1 23, R C, r i Aa r i Cent. Testa NoM6b ' S `" 3 Date z
Gauge # d l/) 2 Z Z V&
Date last accuracy tested Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy