2014_0322 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE X
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1,�2 1 C,5- � B e- 1 + l I' ,,1 e-
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
,�Z Doublet Check Valve ❑ Atmosphere Vacuum Breaker A
Manufacturer Size 1� it
Model Number Located At 'S ` r✓ CO r ri e r t l 74—
Serial Number // 7
The above is certified to be true.
Firm Name 4:LZL/ e2M 6LZ(1A9,1lCertified Tester , r
Firm Address / B f i r(Z-1y a JI Cert. Tester NZLjjj., � - -3 Date 3,-22`61
Gauge # e le 2 Z 2 V�1,,
Date last accuracy tested �/o �-
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 ,'
Opened at
Opened at
osid
Tight �Y
W-1.2 psid
Leaked ❑
Leaked ❑
Dsid
osid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight o
Opened at
Opened at
_osid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name 4:LZL/ e2M 6LZ(1A9,1lCertified Tester , r
Firm Address / B f i r(Z-1y a JI Cert. Tester NZLjjj., � - -3 Date 3,-22`61
Gauge # e le 2 Z 2 V�1,,
Date last accuracy tested �/o �-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy