2014_0321 (4)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: l --?- 3 � % )!a, -'5 b r-
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
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
,2' Double Check Valve ,y ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Located At
Model Number /
Serial Number G% /
The above is certified to be true.
Firm Name4Z A2L
Firm Address � 5-/ 3 2
Gauge # L1 G' � Z
Date last accuracy tested Ch
Certified Tester
Cert. Tester No.� Date
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
Closed Tight ,2
Opened at
Opened at
nsid
Tight
Leaked C3
nsid
nsid
,A8'_psid
Leaked p
/, 5
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ osid
Repair
Tight ❑
nsid
_nsid
RP Sid-
The above is certified to be true.
Firm Name4Z A2L
Firm Address � 5-/ 3 2
Gauge # L1 G' � Z
Date last accuracy tested Ch
Certified Tester
Cert. Tester No.� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy