2014_0213 (22)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.
LOCATION OF SERVICE: � OQ Sau h Cc, CQ J i -yX -� d l _I
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
V Double Check Valve
Manufacturer
Model Number S05 y
Serial Number VK q 0 q 3'
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
f .
The above is certifiers to be true.
Firm Name -TA �-\\
Firm Address 7� S� (21f- c 5 i
Vh,\\A5 Tx �� 7
Gauge # 3 l 7 <6 q
Date last accuracy tested �Q
White - Customer's Copy
4-100�-
Certified Tester M\ 0-\Nt �
Cert. Tester No.�C��'� �� Date 13 1
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 ❑
/Opened at
Opened at
osid
Tight a
RP -psid
Leaked
psid
osid
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_______p sid
Repair
Tight ❑
_osid
osid
RP sid
f .
The above is certifiers to be true.
Firm Name -TA �-\\
Firm Address 7� S� (21f- c 5 i
Vh,\\A5 Tx �� 7
Gauge # 3 l 7 <6 q
Date last accuracy tested �Q
White - Customer's Copy
4-100�-
Certified Tester M\ 0-\Nt �
Cert. Tester No.�C��'� �� Date 13 1
Yellow - City Copy Pink - Tester's Copy