2014_0213 (24)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # ��- fC(C1va
LOCATION OF SERVICE: � OQ 3c)�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 par=eters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer �{ � Size
Model Number �i� Located At
Serial Number WN) \-,A 6
F,
The above is certified to „be true.
Firm Name
Firm Address q C' (,KC 5-T
PhMc\5 Tx 75 �
Gauge # ��317 ' S 9
Date last accuracy tested k � , ?S,
Certified Tester Flo C %�'• �Yl j��3
Cent. Tester No Date
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
Tight ) . �), Z
RP- psid
Leaked o
Closed Tight
Leaked o
Opened at
psid
Opened at
_psid
Did not Open o
psid
Leaked O
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
__ sid
Repair
Tight ®
nsid
psid
RP sid
F,
The above is certified to „be true.
Firm Name
Firm Address q C' (,KC 5-T
PhMc\5 Tx 75 �
Gauge # ��317 ' S 9
Date last accuracy tested k � , ?S,
Certified Tester Flo C %�'• �Yl j��3
Cent. Tester No Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy