2014_0508 (2)CHECK ONE:
IRRIGATION
A s '
DOMESTIC
FIRELINE, L,
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
f�
PWS I.D. #
LOCATION OF SERVICE:
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 C Pressure Vacuum Breaker
❑ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �c%s
Model Number )d 9
Serial Number i jr> ,4,) n
Size /}
Located At flA� ✓� s ��) /u
The above is certified to be true.
Firm Name Au e,:) Lie AI, -fecyo J Certified Tester
Firm Address � W A& RA T 1)12 • 3 `'° Cert. Tester No. r U 4 0 Z Date 5
LA v o, Tip. �5 04
Gauge #
Date last accuracy tested Z - `-%
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
oSid
Tight ❑
Leaked ❑
oSid
oSid
RP- pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
oSid
RP psid
The above is certified to be true.
Firm Name Au e,:) Lie AI, -fecyo J Certified Tester
Firm Address � W A& RA T 1)12 • 3 `'° Cert. Tester No. r U 4 0 Z Date 5
LA v o, Tip. �5 04
Gauge #
Date last accuracy tested Z - `-%
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy