2014_0110 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: S �7 -j
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
w'- Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer I"1 �S Size 3 i 1
Model Number 0 o S Located At i -sC
Serial Number
The above is certified to be true.
Firm Name
C S Certified Testecl IS
Firm AddressG�l"`�� Cert. Testa No. W'_0 13'iSq Date' ' d
Lj
Gauge # Qb /100 .6
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
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Ti_"
Closed Tight
Leaked C
Opened at
osid
Opened at
nsid
nsid
Jh5�
RP -_L ._U sid
Leaked ed C
Did not Open o
Leaked C
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight
Closed Tight o
Opened at
osid
Opened at
osid
nsid
RP =====Psid
The above is certified to be true.
Firm Name
C S Certified Testecl IS
Firm AddressG�l"`�� Cert. Testa No. W'_0 13'iSq Date' ' d
Lj
Gauge # Qb /100 .6
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy