2014_0212 (5)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 6700 Er-e-eA o r -/- 2)4"X
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 OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuum Breaker
111- Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer LU.47`l -6 Size Z 1 r
Model Number D0 7 M / aT Located At A1znr �4 On N• 4 We O
Serial Number q 3
The above is certified to be true.
Firm Name aG Sys ken 5 T ,0, Certified Tester �y n n �• �« e- ti
Firm Address ? 5 T Cert. Tester Nog&Pl 335 -/ D am .?//.2z/
7X
Gauge # /alp/ 33U 3 0
Date last accuracy tested 71Z S�/ 3
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
4112//
DC- Closed
Tight er
RP -1. / Dsid
Leaked
Closed Tight
Leaked ❑
Opened at
vsid
Opened at
nSid
Did not Open ❑
DSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
Dsid
Opened at
nSid
nsid
RP sid
The above is certified to be true.
Firm Name aG Sys ken 5 T ,0, Certified Tester �y n n �• �« e- ti
Firm Address ? 5 T Cert. Tester Nog&Pl 335 -/ D am .?//.2z/
7X
Gauge # /alp/ 33U 3 0
Date last accuracy tested 71Z S�/ 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy