2014_0213 (20)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # k p� 6 m A-)
LOCATION OF SERVICE: _ 10Q 9C)A CO VQJ � TIC -% S 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.
e Reduced Pressure Principle
Double Check Valve
Manufacturer <�— C bC n
Model Number S O'5 Y
Serial Number Vr--3 9 (3, 1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size I '/.)-
Located At WD4 C)
The above is certified to,be true.
Firm Name TA �A
Firm Address 7 � c� �
C4,k\c v, Tk ?5 �
Gauge # t 7 46 9
Date last accuracy tested 9 �
Certified Tester m� L ��• ` cn C 0
Cat Tester No Date 13 t
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
osid
Tight C
Leaked
psid
_nsid
\
RP - _psid
Leaked
Did not Open D
Leaked o
Reps
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight ®
_psid
osid
RP sid
The above is certified to,be true.
Firm Name TA �A
Firm Address 7 � c� �
C4,k\c v, Tk ?5 �
Gauge # t 7 46 9
Date last accuracy tested 9 �
Certified Tester m� L ��• ` cn C 0
Cat Tester No Date 13 t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy