2014_0213 (15)CHECK ONE: f
IRRIGATION DOMESTIC FIRELINE v
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
`�,\Nja cyw,
LOCATION of SERVICE: '3e,A iX\-�L �y A-A 7 5 01 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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer '�—b C o
Model Number i
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size `
Located Ai
The above is certified to be true.
Firm Name TA
Firm Address / � C �
ph�1�s TK ?5 7
Gauge #
Certified Testers
Cert. Tester No ��' 1 1� Date 13 1
Date last accuracy tested _
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
nsid
Tight c
RP -_psid
Leaked o
psid
nsid
Leaked o
Did not Open o
Leaked C3
Repairs
and
`V
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
p sid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true.
Firm Name TA
Firm Address / � C �
ph�1�s TK ?5 7
Gauge #
Certified Testers
Cert. Tester No ��' 1 1� Date 13 1
Date last accuracy tested _
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy