2014_0204CHECK ONE: • r
IRRIGATION DOMESTIC FIRELINE
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #�-� j
LOCATION OF SERVICE: k Imo& DI S -w q!�/ 9 31 S N . D2 yil -oo 771
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuum Breaker
VDouble Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Size
t.
Model Number �U X �' - Located At S 1n� eon �- ► �Q� �S �►' C)
Serial Number �SSO 3 i
The above is certified to be true.
F'um Name C(l( kc oyi Si s- - Cettifwd Tester b u &�t ✓1
Firm Address 16 3Z 61CAV -6 500 f Cat Testa No. 00 12 A , Date
Gauge #
Date last accuracy tested ?j
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
7;7at
Opened at
_paid
Tight
Leaked ❑
Leaked ❑
psid
_ psid
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ nsid
Repair
Tight o
_paid
osid
RP aid
The above is certified to be true.
F'um Name C(l( kc oyi Si s- - Cettifwd Tester b u &�t ✓1
Firm Address 16 3Z 61CAV -6 500 f Cat Testa No. 00 12 A , Date
Gauge #
Date last accuracy tested ?j
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy