2014_0212 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE ✓
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 5-&0 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.
❑ Reduced Pressure Principle
rp-1 Double Check Valve
Manufacturer W A7 r3
Model Number 0 0 7/ 2 cQ T
Serial Number 2 1 G ?,S/ ;,Z_
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 3 /V
Located At h tsar FDC v n N , s)d e 0f
6 /jg. , h P; 4-
The above is certified to be true.
Firm Name 1�✓rrns 1�i .
Firm Address 7' 0 9 5T
,Tip
Gauge # P4,133030
Date last accuracy tested 712 S--// 3
Certified Testa
Cat. Testa No/3320/5 -35-/ Date R11,2L�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight a-
Leaked ❑
Opened at
nsid
Opened at
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
_____p sid
RP sid
The above is certified to be true.
Firm Name 1�✓rrns 1�i .
Firm Address 7' 0 9 5T
,Tip
Gauge # P4,133030
Date last accuracy tested 712 S--// 3
Certified Testa
Cat. Testa No/3320/5 -35-/ Date R11,2L�
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy