2014_0212 (4)CIIECK ONE:
IRRIGATION_ X _
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ,3'DO Ente -oor-+
The baclflow 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
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Q- Double Check Valve 17 Atmosphere Vacuum Breaker
Manufacturer W'4-r-rs Size_?
Model Number nQ 7 M ! !2%T Located At /l/. Si U G 1 " 1.e r±X ti n
Serial Number ! 9 7S'88 •moo /0, �-
The above is certified to be true.
Firm Name 1'ee- �•..s .�rnS Y-n a Certified Tester 70/7rn I• 1<A 4
Firm Address 7S1 / 0 9W` ST Cert. Tester Nol3POV/5-3571 Date R -/ 2 ^ZJ,C
Gauge # ni.l 3 3 o3 d
Date last accuracy tested :2/76;-//-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
P4 S5
DC- Closed
Tight
i'L psid
Leaked ❑
Closed Tight m,
Leaked ❑
% '
Opened at
t?Sid
Opened at
nSid
Did not Open o
nSid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
osid
_____-p sid
RP sid
The above is certified to be true.
Firm Name 1'ee- �•..s .�rnS Y-n a Certified Tester 70/7rn I• 1<A 4
Firm Address 7S1 / 0 9W` ST Cert. Tester Nol3POV/5-3571 Date R -/ 2 ^ZJ,C
Gauge # ni.l 3 3 o3 d
Date last accuracy tested :2/76;-//-3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy