2014_0207CHECK ONE:
IRRIGATION /_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /I l
D. ^dwoaA yrmu SL
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.
TYPE 0
ASSEMBLY
Reduced Pressure Principle
C Pressure Vacuum Breaker
Double Check Valve
C Atmosphere Vacuum Breaker
Manufacturer Q1 l—K( tJ6 Size
g5oXL_7- z Located
At / "(k -T�� S• 7RAAkL
Model Number
Serial Number , 3 8 q � 9 92—
REDUCED PRESSURE PRINCIPLE
ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
'ti Test
DC- Closed
Xlosed Tight
Opened at
Opened at
oSid
Tight
Leaked ) C
oSid
oSid
RP -�sid
Leaked C
Did not Open C
Leaked
Reps
and
Materials
Used
Test After DC- Closed I Closed Tight o Opened at Opened at osid
Repair Tight C oSid osid
RP oSid
The above is certified to be true. ��Q��
Firm Name bJK 3VA&L l [[�� JIW t CcrtifiedTesta b0AIVIL 6W7'
Firm Address 15, A 9 47 CerG ester No. bJqWe0l Date
Gauge # 90/.
Date last accuracy tested 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy