2014_0213 (26)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D.#
LOCATION OF SERVICE: & Pit
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
s� Double Check Valve
Manufacturer ` f ( C
Model Number 1
Serial Number �� - O; `
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
0 Atmosphere Vacuum Breaker
Size f d ' r
Located At
The above is certified to be true.
Firm Name���'�
Firm Address 1 � G �
Gauge # 331 % <6 q
51
.7 51.-7
Date last accuracy tested �
White - Customer's Copy
Certified Testers
Cent. Tester No.'�O'C>L 1'0 0 Date
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 j ,
RP ------ psid
Leaked o
Leaked o
osid
_ nsid
Did not 0pen o
Leaked C3
Repairs
and
Materials
Used
Test Agar
DC- Closed
Closed Tight o
Opened at
Opened at
___-_-p sid
Repair
Tight n
osid
�psid
RP 2sid
The above is certified to be true.
Firm Name���'�
Firm Address 1 � G �
Gauge # 331 % <6 q
51
.7 51.-7
Date last accuracy tested �
White - Customer's Copy
Certified Testers
Cent. Tester No.'�O'C>L 1'0 0 Date
Yellow - City Copy Pink - Tester's Copy