2014_0213 (19)CHECK ONE:
IRRIGATION DOMESTIC FIR.ELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # is 06 mo-A 3
LOCATION OF SERVICE: � oC 3 A
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
51/ Double Check Valve
Manufacturer Ch C
Model Number Q�J�
112 - Serial Number 1 � 0
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
D Atmosphere Vacuum Breaker
I/ I i
Size p
Located At 1>1� Z
The above is certified to be true.
Firm Name �c� �+�'�� �� , . Certified Tester Cllr (-h
Firm Address-7 � C C.c � 22 Cert. Tester No � � �I g �� Date
Gauge # l 7 < q
Date last accuracy tested k, _
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 C
Opened at
Opened at
psid
Tilt c
Leaked
psid
nsid
1
RP -psid
Leaked
Did not Open o
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
___ nsid
Repair
Tight 13
Dsid
nsid
RP sid
The above is certified to be true.
Firm Name �c� �+�'�� �� , . Certified Tester Cllr (-h
Firm Address-7 � C C.c � 22 Cert. Tester No � � �I g �� Date
Gauge # l 7 < q
Date last accuracy tested k, _
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy