2014_0128 (2)CHECK ONE:
IRRIGATION 'V'
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
(\ C,,L (A. C-
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
.S,"' Double Check Valve
Manufacturer � l s L '� t
Model Number 3 c) 0
Serial Number 3 Q)
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At .` t r`G� c��'X. �i�►"'�
The above is certified to be true.
Firm Name n (`5 &L-L � ,j Certified Tester 00,y A. to k-C-`)
Firm Address �12 Ow t+ i Cent. Testa No. MOO jSjij Date 9
Gauge # L
Date last accuracy tested 30 —13
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 '
Opened at
Opened at
nsid
vzoliq
61
Tigh t
1Z - _.__psid
Leaked ❑
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name n (`5 &L-L � ,j Certified Tester 00,y A. to k-C-`)
Firm Address �12 Ow t+ i Cent. Testa No. MOO jSjij Date 9
Gauge # L
Date last accuracy tested 30 —13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy