2014_0213 (10)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACXTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # NV�m(V -4`)
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
9� Double Check Valve
Manufacturer C o
Model Number I
Serial Number Vz -7 ^
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size I /, �,
Located At xx)�> A I, 5 (F—
The above is certified to. be true.
Firm Name
Firm Address C C c 5'i
P(\�1a5 Tx 75 �
Gauge # 33 17 ' S 9
Date last accuracy tested
Certified rester ( c 06 \W�
Cent. Tester No.`ti���� � � �� Date
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- Closest
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
RP- _pSid
Leaked ❑
osid
oSid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
__paid
Repair
Tight ❑
------psid
oSid
RP Sid
The above is certified to. be true.
Firm Name
Firm Address C C c 5'i
P(\�1a5 Tx 75 �
Gauge # 33 17 ' S 9
Date last accuracy tested
Certified rester ( c 06 \W�
Cent. Tester No.`ti���� � � �� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy