2014_0321 (2)CIIECK ONE:
IRRIGATION
DOMESTIC X FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1 -23 el /" el- k-6 S k f' C1,1—
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
,2'
Double Check Valve
Manufac=er
�
Model Number
Serial Number
2nd Check
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size /,, /`
Located At X�k� � -S //"�`
The above is cerdfied to be true.
Firm Name �t L.�Certified Tester ,� v
Firm AddresQ �� � i `��/C� �i ;� ir CerL Tester No. s _ Date
Gauge # ��l G e- Z Y l
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
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
mod"
Closed Tight `0
Leaked o
Opened at
p id
Opened at
nsid
vsid
;Tijp� sid
Lea ❑
Did not Open 13
Leaked C3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
vsid
_nsid
RP sid
The above is cerdfied to be true.
Firm Name �t L.�Certified Tester ,� v
Firm AddresQ �� � i `��/C� �i ;� ir CerL Tester No. s _ Date
Gauge # ��l G e- Z Y l
Date last accuracy tested -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy