2014_0530CIIECK ONE:
IRRIGATION L DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 77
The baclflow 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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
^_ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
6J�cJ
Serial Number Li
Size
Located At
The above is certified to be true.
//��
Firm Name KPS� J, r Certified Tester S
Firm Address ,U Cat Tester No. Q� o �k Date
Gauge # 22A)VIV It
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
:fir Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
Tight ❑
RP- � Dsid
Leaked ❑
esid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
esid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
//��
Firm Name KPS� J, r Certified Tester S
Firm Address ,U Cat Tester No. Q� o �k Date
Gauge # 22A)VIV It
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy