2014_0523CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
A
LOCATION OF SERVICE: i- O Y cb T rd.
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer �E' --kJ C (": Size
Model Number �l Located At
Serial Number H -b L� q 2, 7L
The above is certified to be true.
Firm Name -_T Certified Tester �,'p r►p ,, - -.
Firm Address - .Cert. Tester No. �RPnnn����/ Date
?°X 7
Gauge # ` F) I () [Lag
Date last accuracy tested .). -- V� — I t
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
1st Check
2nd Check
Initial Test
DC- Closed
Tight ❑
Closed Tightl-44
Leaked ❑
Opened at
-sid
Opened at
Sid
oSid
R.P -_pSid
Leaked D
Did not Open D
Leaked C3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight D
Opened at
Sid
Opened at
oSid
osid
RP Sid
The above is certified to be true.
Firm Name -_T Certified Tester �,'p r►p ,, - -.
Firm Address - .Cert. Tester No. �RPnnn����/ Date
?°X 7
Gauge # ` F) I () [Lag
Date last accuracy tested .). -- V� — I t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy