2014_0322 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Z j 2 Z Zr 4tom'. ,ems-%
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.
❑ Reduced Pressure Principle
'Or Doublle� Check Valve
Manufacturer (i`� �-
Model Number CiC) 7 111 !
Serial Number / i-� P& 4
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size JJ J
Located At
The above is certified to be true.
Firm Name .Ll ALL—, rr dLA (/KCartified Tester -
Firm Address A= Cent. Testa No. &A) , :3 Date
Gauge # �1G' o? -1 a VCy
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 Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Z
Opened at
Opened at
osid
Tight ,Er
jUk,2. 1 psid
Leaked ❑
Leaked ❑
`
>?sid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight
osid
osid
RP psid
The above is certified to be true.
Firm Name .Ll ALL—, rr dLA (/KCartified Tester -
Firm Address A= Cent. Testa No. &A) , :3 Date
Gauge # �1G' o? -1 a VCy
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy