2014_0506CHECK ONE.
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1,-� �C� I � ►h <j
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
Model Number LJ 009 M 2�Z
Serial Number d 1Srnlea
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
") /N, s.�
The above is certified to be true.
Firm Name �-uti� f`� Fl 6Cf 1r� ) �. nC Certified Tester ��J-aJ Vf' n e
Firm Address � r �'� -75O.P9 Cart. Tester No. Date '1--(p -_L4
Gauge #
Date Last accuracy tested 7)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
Bw �
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 ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP -_ psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
UeAn
4-
}}
t U S
r C kt
<_s S e- Prt
-'+° r
j
Test After
Repair
DC- Closed
Tight
Closed Tight ❑
Opeaed at
. R osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name �-uti� f`� Fl 6Cf 1r� ) �. nC Certified Tester ��J-aJ Vf' n e
Firm Address � r �'� -75O.P9 Cart. Tester No. Date '1--(p -_L4
Gauge #
Date Last accuracy tested 7)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
Bw �