2014_0213 (25)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: L OQ 90u'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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number
Size
Located At
The above is certified to be true.
Firm Name Kok A� c
Firm Address-7 q o q Cz S 5`7"
90 -5 Tk 75aa7
Gauge # - -
Date last accuracy tested �0 I
Certified Tester �c1no.�
Cert. Tester No. -)?M\ y � 1-7 Date a 3 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
Leaked Q
nsid
oSid
RP- _—psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
vSid
oSid
RP sid
The above is certified to be true.
Firm Name Kok A� c
Firm Address-7 q o q Cz S 5`7"
90 -5 Tk 75aa7
Gauge # - -
Date last accuracy tested �0 I
Certified Tester �c1no.�
Cert. Tester No. -)?M\ y � 1-7 Date a 3 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy