2014_0213 (11)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
,,�-�CC Cyy k2�rf\(tAn
LOCATION OF SERVICE: TX —) S 0 I q
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.
TYPE OF ASSEMBLY
Reduced Pressure Principle a Pressure Vacuum Breaker
~ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer
Model Number
-,(�X(.)
19( y
Serial Number ! r_ Isq 55
size
Located At 1 S�Z15C
The above is certified to be true.
Firm Name
Firm Address C -c<- c 5 i
C Oi -5 Tx 7 5 7
Gauge # 32) t 7 6 q
Date last accuracy tested r Q
Certified Testae
Cat. Teaer No � i �� Date 13 1
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
Closed Tight o
Opened at
Opened at
osid
Tight ❑
RP ----psid
Leaked
Leaked
osid
1psid
Did not Open o
Leaked EO
Reps
and
Materials
Used
Test Afar
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ®
osid
osid
RP sid
=��l
The above is certified to be true.
Firm Name
Firm Address C -c<- c 5 i
C Oi -5 Tx 7 5 7
Gauge # 32) t 7 6 q
Date last accuracy tested r Q
Certified Testae
Cat. Teaer No � i �� Date 13 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy