2014_0212 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE - t/
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: SC) d Fr e-4 o f-
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer 1,6 ATE S
Model Number r o7 In/ 1017
Serial Number S'_ �' b 0 7
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size
Located At &Z
The above is certified to be true.
Firm Name Pae S 2n - Certified Tester J-o k r re
13P
Firm Address -75"1 t D 9 "*� S 7- Cat. Taster No. Date
4r lint' ton , 7-X
Gauge # t9 !o/ 3 3 030
Date last accuracy tested 7 Z e-l/ -
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
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
/
Tight a
Leaked ❑
psid
oSid
Rp_ 2.2 osid
Leaked ❑
3 •
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Ater
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
oSid
oSid
R.P sid
The above is certified to be true.
Firm Name Pae S 2n - Certified Tester J-o k r re
13P
Firm Address -75"1 t D 9 "*� S 7- Cat. Taster No. Date
4r lint' ton , 7-X
Gauge # t9 !o/ 3 3 030
Date last accuracy tested 7 Z e-l/ -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy