2014_0321CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L,2-,-)7 e-
/`l-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.
TYPE OF ASSEMBLY
c Reduced Pressure Principle a Pressure Vacuum Breaker
,2' Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer f' . Size
Model Number �� -� Located At 11 #0
Serial Number / 2d 52-
The above is certified to be true.
Firm Name i _� allllcertified Testa , �-, /�/l�✓ rt
Firm Address,-;),'S -/ �� /u /� l� Cert. Testa No. &1011 IS `' Date
Gauge # f G 2 z Z (/&
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight z
-,Fd5=_2 psid
Leaked p
Closed Tight -ET
Leaked o
7-
Opened at
vsid
Opened at
vsid
Did not Open o
vsid
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
vsid
Opened at
vSid
_psid
RP sid
The above is certified to be true.
Firm Name i _� allllcertified Testa , �-, /�/l�✓ rt
Firm Address,-;),'S -/ �� /u /� l� Cert. Testa No. &1011 IS `' Date
Gauge # f G 2 z Z (/&
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy