2014_0213 (21)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: JQL)Jb N \AC �y�4la
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer '!�-& C
Model Number
Serial Number Mon I'"I
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size I 'l.)
Located At �VD * '6
s
The above is certified to be true.
Firm Name
Firm Address -
V4,k\A5 Tf <
Gauge # 3?, l 7 <6 �
Date last accuracy tested -�j b A
White - Customer's Copy
Certified Tester�C�rc.{
Cert. Tester No.�'1 �� Date 3 I
Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
lst Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight o
Leaked
psid
osid
'N
RP -_psid
Leaked
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
--___—p sid
Repair
Tight ®
nsid
osid
RP sid
s
The above is certified to be true.
Firm Name
Firm Address -
V4,k\A5 Tf <
Gauge # 3?, l 7 <6 �
Date last accuracy tested -�j b A
White - Customer's Copy
Certified Tester�C�rc.{
Cert. Tester No.�'1 �� Date 3 I
Yellow - City Copy Pink - Tester's Copy