2014_0213 (16)CHECK ONE: `
IRRIGATION DOMESTIC FIRELINE'
BACW'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # N u A mf -yp
LOCATION OF SERVICE: p -)A N yyk v ` ca pp I `' -� 5 0 1 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.
Reduced Pressure Principle
� Double Check Valve
Manufacturer yr, C 0,
Model Number � J Y
Serial Number P0
TYPE OF ASSEMBLY
Cl Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size ( /2
Located At 0 3 �Z' 5
s
The above is certified to be true.
Firm Name
Firm Address
Nh \A,5 1X ?5 �
Gauge # 3 3 17 iS q
Date last accuracy tested
Certified Tester (110 C,�1�•�, � c� � C, i £`, �'�
Cat Tester 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
Closed Tight O
Opened at
Opened at
vsid
\
�V1
Tight ❑
RP -_psid
Leaked ❑
Psid
vsid
Leaked ❑
Did not Open O
Leaked O
Repairs
Conr�(,A
c4 CA
GAT�- W
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
vsid
Repair
Tight O
vsid
vsid
RP sid
s
The above is certified to be true.
Firm Name
Firm Address
Nh \A,5 1X ?5 �
Gauge # 3 3 17 iS q
Date last accuracy tested
Certified Tester (110 C,�1�•�, � c� � C, i £`, �'�
Cat Tester No Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy