2014_0603 (10) I CHECK ONE:
IRRIGATION DOMESTIC I I FIRELINE I 1
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL /
PWS I.D. #
LOCATION OF SERVICE: US Postal Service, 951 W. Bethel Road
The bac3flow prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
0 Reduced Pressure Principle c Pressure Vacinma+ Breaker
Q Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer Ames S1ze 4"
Model Number 2000 Located At Riser # 3
Serial Number 1 01 2E02
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Chew 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight iK1 Opened at Opened at paid
Tight in Leaked O osid psid
RP - s
t /
Leaked p a .'O Did not Open o Leaked o
1 Repairs
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at osid
Repair Tight o paid osid
RP osid
The above is certified to be true.
Firm Name Professional Backflow Certified Tester Scott Masdon Q —
Firm Address 5068 Avery, The Colony Cent Tester No. 2524 De 06/03/14
Gauge # 002013
Date last accuracy tested 03/03/14
White - Customer's Copy Yellow - City spy Pink - Tester's Copy