2014_0213 (17)CIIECK ONE: I/
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # A y�mo A —)
LOCATION OF SERVICE: � OQ 9�)A Co pocM Tx 7 5 0 I _I
The backflow 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 ChC
Model Number
05'
Serial Number 39 S5
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
I J�, 1
Size
Located At��
IF
The above is certified to be true.
Firm Name -TA �-+\ '�",rk
Firm Address 7 g� q C y<- C `5T
V7 MO,5 TK .75-D -al
Gauge # -� l % <S q
Date last accuracy tested
Certified Tester M\ t 1- Nt i
Cert. Tester No.�'�� �� Dated 13
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 0
Opened at
Opened at
osid
Tight ❑
RP- _,psid
Leaked 4(
Leaked
osid
osid
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight ®
osid
osid
RP sid
IF
The above is certified to be true.
Firm Name -TA �-+\ '�",rk
Firm Address 7 g� q C y<- C `5T
V7 MO,5 TK .75-D -al
Gauge # -� l % <S q
Date last accuracy tested
Certified Tester M\ t 1- Nt i
Cert. Tester No.�'�� �� Dated 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy