2014_0214CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
i
LOCATION OF SERVICE: ZI Q �Z 1 �7 f e- ft ,�- !, T C l
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer Cdr
Model Number cy
Serial Number kJ c — .T % % L-
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size iy
Located At�''`�
The above is certified to be true.
)UM BREAKER
Check Valve
oSid
Leaked ❑
nSid
Gandara 14
ROOM= Name =1 Clifton Dr. Certified Tester
c a n 7
Firm Address Cert. Tester No.`� /%� Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Closed Tight e
Opened at
Opened at
Tight
RP -)sid
Leaked ❑
Leaked 0
nsid
osid
Did not Open o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
nsid
oSid
RP psid
The above is certified to be true.
)UM BREAKER
Check Valve
oSid
Leaked ❑
nSid
Gandara 14
ROOM= Name =1 Clifton Dr. Certified Tester
c a n 7
Firm Address Cert. Tester No.`� /%� Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy