2014_0213 (18)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # �' �� C OY� M t -4-)
LOCATION OF SERVICE: COQ 9Q) h CCU y!Q J i ` y,
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 `f �C ()
Model Number W6, t
Serial Number li3 r— 3 9 7Q
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size l V--Z
Located At ttu -* l I V � 'SE
The above is certified to. be true.
Firm Name A FA C' ,
Firm Address? 9a C.tr c 5
Tt < ?5 7
Gauge # .317 q
Date last accuracy tested ' Q y
Certified Testes
Cert. Tester No �� Date I 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 0
Opened at
Opened at
osid
Kv
Tight ❑
RP -_psid
Leaked
osid
osid
Leaked
Did not Open C3
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
psid
Repair
Tight
�psid
osid
RP sid
The above is certified to. be true.
Firm Name A FA C' ,
Firm Address? 9a C.tr c 5
Tt < ?5 7
Gauge # .317 q
Date last accuracy tested ' Q y
Certified Testes
Cert. Tester No �� Date I 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy