2014_0110 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 07 1 ly/
NWA
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.
e Reduced Pressure Principle
Doublet Check Valve
Manufacturer
Model Number Q 0
Serial Number
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
11/ 11
Size
Located At mucK
The above is certified to be true. �
Firm Name i TC-5 r Certified Tester ,, a(I l�r��
Firm Address ,L/-iw� �I hf,.(j (ktp' Cert. Tester No. % Date ''
Gauge # 4 %/06( J
r
Date last accuracy tested S L ;�-`
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
�fn S
S
DC- Closed
Tight
RP- i osid
Leaked ❑
Closed Tight e
Leaked ❑
Opened at
osid
Opened at
osid
Did not Open a
osid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
osid
osid
RP sid
The above is certified to be true. �
Firm Name i TC-5 r Certified Tester ,, a(I l�r��
Firm Address ,L/-iw� �I hf,.(j (ktp' Cert. Tester No. % Date ''
Gauge # 4 %/06( J
r
Date last accuracy tested S L ;�-`
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy