2014_0321 (3)CHECK ONE:
IRR.IGATION___,�L_
DOMESTIC
W tzAafl Zt�+
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 12 31 A� 51 v,- ell
The bacl&ow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is terrified to be operating within acceptable parameters.
Reduced Pressure Principle
;Y Double Check Valve
Manufacturer //t,/A L/
Model Number !` �7 Al 1
Serial Number <F� 1 1 q
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name / t/1� l c{�i� �,�i� Certified Tester��i v, /� ✓% Pte;
Cent. Tester No. W 5 Date
Gauge # 610 z Z L V (p
Date last accuracy tested cle -
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
-LI-psid
Closed Tight Z
Leaked ❑
Opened at
Dsid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_____p sid
RP sid
The above is certified to be true.
Firm Name / t/1� l c{�i� �,�i� Certified Tester��i v, /� ✓% Pte;
Cent. Tester No. W 5 Date
Gauge # 610 z Z L V (p
Date last accuracy tested cle -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy