2014_0212CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: .5-00 A-e e-Iao r * P1 u j
The bacltilow 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 ❑ Pressure Vacuum Breaker
211 Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer /, ,47?` S Size 91
Model Number -7-714 X 6 Gr-)A Located At &04:5 15Ue- &� Qd , 5e
Scrial Number -/-0f2-6-,2?//0Z
The above is certified to be true.
Firm Name Pam ,6-k w6 Z'nG •
Firm Address 7 s/ / y 9 5 T
r/ivI_11O✓7,7-Y-
Gauge # 196/ 3 30 3 0
Date last accuracy tested 7 l2 S— %/ '3
Certified Tester n A ,
13P
Cert. Tester No. ,DO /S'S/ Date /Z /'/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Cbeck Valve
1st Check:
2nd Check:
Initial Test
Z - i L 'Iy
.�/
DC- Closed
Tight ❑
RP -.psid
Leak-
Closed Tight ❑
Leaked 2-
P1
Opened at
osid
Opened at
osid
Did not Open o
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
11
Rp sid
The above is certified to be true.
Firm Name Pam ,6-k w6 Z'nG •
Firm Address 7 s/ / y 9 5 T
r/ivI_11O✓7,7-Y-
Gauge # 196/ 3 30 3 0
Date last accuracy tested 7 l2 S— %/ '3
Certified Tester n A ,
13P
Cert. Tester No. ,DO /S'S/ Date /Z /'/
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy