2014_0323 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: fir I - 1 1 ! t'04, f,
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
Manufacturer &l , 718
Model Number 60 -7 M l
Serial Number S- L/ 02 &
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size f
Located At
The above is certified to be true. /�
Firm Name �, " Mlle l Certified Testa
Firm Address 5 /� r �; ��� Cat Testa Nor. u Date ' Z
Gauge # 616 2 2 Z V- (d
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
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ,�
3_� psid
Leaked 13
Closed Tight /"-!"
Leaked ❑
.�
" �
Opened at
vsid
Opened at
osid
Did not Open ❑
o sid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
------p sid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true. /�
Firm Name �, " Mlle l Certified Testa
Firm Address 5 /� r �; ��� Cat Testa Nor. u Date ' Z
Gauge # 616 2 2 Z V- (d
Date last accuracy tested - -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy