2014_0110 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE I
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE-061 i`'1CILL(fk &I) Y C` 15-Xelj
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.
C Reduced Pressure Principle
Double Check Valve
( 1
Manufacturer ' 1 16
Model Number 1,3000 SS
Serial Number N -1 1�4 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name f �C______ Certified Tester (,,A (I Sc, x(8-44—
Firm Address PJGI M �4 P 0to�Cert. Taster No P40 �3��� Date ' /01
Gauge # 0 6 116 fj6 � _
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
is Check:
2nd Check
Initial Test
TRP-
O-55
DC- Closed
Tight
:,. osid
Leaked ❑
'Closed Tight elf
Leaked ❑
a, �j
Opened at
osid
Opened at
oSid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
oSid
Sid
RP sid
The above is certified to be true.
Firm Name f �C______ Certified Tester (,,A (I Sc, x(8-44—
Firm Address PJGI M �4 P 0to�Cert. Taster No P40 �3��� Date ' /01
Gauge # 0 6 116 fj6 � _
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy