2014_0322 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACSFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: /702 I ff/" 4 e
The back-flow 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
12' Double Check Valve
Manufacturer �d lq5
Model Number . 613 7 /L
Serial Number 3 1 <�
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size `� z
Located At t-2
The above is certified to be true.
Firm Name iXertified Tester
Firm Address S % �i l,'r_� ���,y� dl- Cert. Tester No.�li /� �'' 3 Date -
Gauge # 61612- z z `f�
Date last accuracy tested y -27
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight z
Opened at
Opened at
nsid
Tight Z
JUk' �?� psid
Leaked ❑
Leaked ❑
psid
nsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
—__--.p sid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Name iXertified Tester
Firm Address S % �i l,'r_� ���,y� dl- Cert. Tester No.�li /� �'' 3 Date -
Gauge # 61612- z z `f�
Date last accuracy tested y -27
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy