2014_0521CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
(APL
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: rl 15-,, Al a c- 11 �4 t,� U,," F [ ye -1
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
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At G
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
�� ��C C,
Model Number
Serial Number
T �;Z 3
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At G
The above is certified to be true. LL
Firm Name--if f A Nl P f- 14,t% Certified Tester ' � ' &
Firm Address , SS l'3 i' C,z C j I ik Jd I- Cert. Testa No. kR 1 S3 Date
Gauge # 01 L 227- q (
Date last accuracy tested 11
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
Tight .e
Leaked ❑
Closed Tight id
Leaked ❑
�
Opened at
a ' osid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
nSid
oSid
RP sid
The above is certified to be true. LL
Firm Name--if f A Nl P f- 14,t% Certified Tester ' � ' &
Firm Address , SS l'3 i' C,z C j I ik Jd I- Cert. Testa No. kR 1 S3 Date
Gauge # 01 L 227- q (
Date last accuracy tested 11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy