2014_0204 (2)CHECK ON
IRRIGATION DOMESTIC
FIRELINE"
BACImOW PREVENTION ASSEMBLY TEST AND MAINPENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: t ���C { 7.x '
The back-flow prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Brea
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacnaer 1�j: lkc yr S Size )/ a t t
Model Number l S0 L` Located At V-j ° `o
Serial Number 533
1
The above is certified to be true.
Firm Name f'i 20 .A 1 NkC�Okl SI S Cadfied Testa t) 0 S' V v1
Firm Add= MaCk 9,10 fU Cent. Tester No. Date
pC<4 (rte 45A36
Gauge # 11C ®�
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
Cheek Valve
Initial Test
DC- Closed
Closed Tight
Opened,ht
Opened at
_psid
P�
Tight
�•�psid ❑
Leaked ❑
p sid
_psid
Did not Open o
Leaked (3
Repairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opened at
Opened at
flsid
Repair
Tight 13
sid
_- sid
RP id
The above is certified to be true.
Firm Name f'i 20 .A 1 NkC�Okl SI S Cadfied Testa t) 0 S' V v1
Firm Add= MaCk 9,10 fU Cent. Tester No. Date
pC<4 (rte 45A36
Gauge # 11C ®�
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy