2014_0110CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # p ) /
LOCATION OF SERVICE: 951 A . � �—f �'`1�` L1 4
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
C.-' Double Check Valve
Manufacturer
Model Number
o
Serial Number H 19 31 1
TYPE OF
size
ASSEMBLY
❑ Pressure Vacuum Breaker
n Atmosphere Vacuum Breaker
�t
Located At
The above is certified to be true.
Firm Name
C 5 Certified Tester
I L4
Firm Address D ^
�/ � r �� Cert. Tester No. B Poe 13 Date
Gauge # (56/1006 9
Date last accuracy teste C
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
71S
DC- Closed
TiW4 `�
RP- sid
Leaked ❑
losed Tight
Leaked ❑
• a
Opened at
Dsid
Opened at
osid
Did not Open ❑
osid
Leaked ❑
Reps
and
Materials
Used
Test ARer
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
C 5 Certified Tester
I L4
Firm Address D ^
�/ � r �� Cert. Tester No. B Poe 13 Date
Gauge # (56/1006 9
Date last accuracy teste C
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy