2014_0226 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE N/
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
CG�rc).
The bacUow 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 �'�
Modes Number
- -
Serial Number t .�
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Sizel� , t
Located At
'' P1/n :d-
The above is certified to be true.
Firm Name'l =< Certified Tester rr. :- � �.1 a 1"ds—a
Firm Address'i- , F)as `225% ,'T,� Cert. Tester No. 73 � s , Date ?' l
Gauge #
Date last accuracy tested f ,�' � -1 j
J� F L
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
a �
°� loo' 1
Tight
RP- . ,•� psid
Leaked p
Leaked C
asid
nsid
Did not Open o
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight
nsid
nsid
RP sid
The above is certified to be true.
Firm Name'l =< Certified Tester rr. :- � �.1 a 1"ds—a
Firm Address'i- , F)as `225% ,'T,� Cert. Tester No. 73 � s , Date ?' l
Gauge #
Date last accuracy tested f ,�' � -1 j
J� F L
White - Customer's Copy Yellow - City Copy Pink — Tester's Copy