2014_0715 CIIECK ONE:
IRRIGATION DOMESTIC ✓ FIRELINE
BACKFi.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 1- 1 `T N au Cl
The baclelow prevention assembly detailed below has been tested and rrlairnrained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Ci Reduced Pressure Principle 0 Pressure Vacuum Breaker
Double Check Valve D Atmosphere Vacuum Breaker
Manufacturer
\A1 i; Size r
Model Number 1.._F 007 M 1 Q \ Located At --k--t°,1,7 / --S • -
Serial Number
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check 1 2nd Check Relief Valve Air Inlet Cheek Valve
Initial Test (DC-Clot $ / ' Opened at Opened at nsid
Tight [i1 L - -- 0 nsid osid
fi S•S ) RP- nsid
Leaked o Did not Open o Leaked o
Reps
and
Materials
Used
Test After DC- Closed Closed Tight o Opened at Opened at nsid
Repair Tight nsid osid
RP psid
The above is certified to be true.
Firm Name 12) i S121C� n � - kiv i� �, -- Certified Tester t r° N /t°r i S rl "j .
Firm Address p --)1_,=„ L' i `�/� / / Cert. Tester No. - ala< :>37r 2?�Date - 7 - / /
Gauge # r) .R i n / l,-7 - y
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy