2014_0213 (23)CHECK ONE: /
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: � OQ p- h)A c p(M 1--K 7 5 o I 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_
Model NumberQ����
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size I IL
Located At Dvp l-� Z, XIK
The above is certified to be true.
Firm Name —icy
Firm Address? C.c ^r 5-T
Tx 5 a
Gauge # 3 2)
Date last accuracy tested =-f- -s
Certified Tester
Cert. Testa No Date 13 I
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
j)
DC- Closed
Tight a
R.P- __psid
Leaked o
Closed Tight 9/'
Leaked o
Opened at
osid
Opened at
oSid
Did not Open o
osid
Leaked o
Repairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight t,
Opened at
Opened at
_______nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name —icy
Firm Address? C.c ^r 5-T
Tx 5 a
Gauge # 3 2)
Date last accuracy tested =-f- -s
Certified Tester
Cert. Testa No Date 13 I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy