2014_0226 (4)CIIECK ONE:
IRRIGATION_ `�
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: J 5N E&—U+1-("r-1- yakio;ta 11120 -6 Sfi n- tULck
The baci3low 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
;i Double Check Valve
Manufacturer
Model Number
Serial Number`1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
�
Size
Located At /I �: �P. / Ufa.
The above is certified to be true.
Firm Name r Certified Tester :,"y'k r �
Firm Address i`" /_y. r15 Cert. Tester No. -G
Date �
Gauge # '
�fc�71 7
Date last accuracy tested /1), -31 ,3
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
a'aly 1�
DC- Closed
Tight
RP- ypsi
Leaked ❑
Closed Tight
Leaked ❑
Opened at
nSid
Opened at
vSid
Did not Open ❑
vsid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
osid
oSid
RP sid
The above is certified to be true.
Firm Name r Certified Tester :,"y'k r �
Firm Address i`" /_y. r15 Cert. Tester No. -G
Date �
Gauge # '
�fc�71 7
Date last accuracy tested /1), -31 ,3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy