2014_0603 (11) CIIECK ONE:
IRRIGATION DOMESTIC I I PIRELINE I ✓ I
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. i!
LOCATION OF SERVICE: US Postal Service, 951 W. Bethel Road
The baciclow 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
Q Reduced Pressure Principle 0 Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Hersey 4"
Manufacturer Size
Model Number DC ocar -. At Riser # 2
L {
Serial Number 8019883
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheek 2nd Check Relief Valve Air Inlet Check Valve
Initial Test DC- Closed Closed Tight �] Opened at Opened at paid
Ti CO Leaked o nsid _�sid
RP- - sid
Leaked o ' �_ Did not Open O Leaked J
Repairs
and
Materials
Used
Test After DC- Closed Closed Tight a Opened at Opened at �sid
Repair Tight nsid nsid
RP nsid
The above is certified to be true.
Firm Name Professional Backflow Certified Testa Scott Masdon
Firm Addre= 5068 Avery, The Colony Cert. Testa No. 2524 Dare 06/03/14
Gauge # 002013
Date last accuracy tested 03/03/1
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy