2014_0213 (13)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE Y
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # Or\ ` NEE' M
LOCATION OF SERVICE: � OQ 5�)A M"\C �V�k u c Cn w(- ` Tx 7 5 p 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 par=eters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
9( Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �E�C Size j ' f
Model Number 905 y Located At 1�--
Serial Number V3 K W O�
The above is certified to. be true.
Firm Name 7A �\\
Firm Address G q C a: ,c 5i"
?5,,),-�)7
Gauge # ��317 `5 9
Date last accuracy tested
Certified rester M\ 0-\c�.�t
Ceri. Testa No 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- Closed
Tight a/
� Dsid
Leaked o
Closed Tight
Leaked 0
0
Opened at
psid
Opened at
_� sid
Did not Open o
Dsid
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight n
nsid
Dsid
RP sid
The above is certified to. be true.
Firm Name 7A �\\
Firm Address G q C a: ,c 5i"
?5,,),-�)7
Gauge # ��317 `5 9
Date last accuracy tested
Certified rester M\ 0-\c�.�t
Ceri. Testa No Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy