2014_0204 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE'
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: VLL no S li j t Deyd-60 7 &xod U % -rX
The bacld]ow 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
V Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer k>J L t "W--, Size -./q Y E
Model Number l &0 X L ° Located At S • VJ � OO&iJR0, � i ►22 PC's 5
Serial Number H 4)- q 0 7�- ri
The above is certified to be true.
o r
Firm Name h 2Q kl ?R(Al"I SIS, CatiSed Tester
Firm Address 16 UQ Mad4 sulk, 9-ck Cat. Testa No. 0a l Date �,1 1 %
n��4 s (max � S�
Gauge # 11C S -0
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
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
P&';5
DC- Closed
Tight
RPa--&—p sid
Lead -ad 0
Closed Tight
Leaked 0
Opened it
psid
Opened at
_psid
Did not Open 0
� id
Leaked ❑
Repairs
„
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight o
Opened at
psid
Opened at
_,_psid
__ psid
RP aid
The above is certified to be true.
o r
Firm Name h 2Q kl ?R(Al"I SIS, CatiSed Tester
Firm Address 16 UQ Mad4 sulk, 9-ck Cat. Testa No. 0a l Date �,1 1 %
n��4 s (max � S�
Gauge # 11C S -0
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy