2014_0523CHECK ONE:
IR.RIGATION—X-_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: -to" 5 i gl, t 4 xn 6 I Vc4
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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
M Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer 1—,a k,",<) Size
Model Number
Serial Number -33 7g�
Located At
The above is certified to be true.
Firm Name At U Certified Tester ✓V� ' +�'�
Firm Address '��� �'4' u Cert. Tester No. ��� Q 1 ?'17 t? Date — y
v /Nwn ;�75�e
Gauge
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
Closed Tight ❑
Opened at
Opened at
nsid
/
�(
-- Z 3-14
Tight 2 sid ❑
,p
Leaked ❑
Leaked o
nsid
oSid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name At U Certified Tester ✓V� ' +�'�
Firm Address '��� �'4' u Cert. Tester No. ��� Q 1 ?'17 t? Date — y
v /Nwn ;�75�e
Gauge
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy