2014_0213 (27)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND N[AINTENANCE REPORT
NAMZ OF PWS: CITY OF COPPELL
PWS I.D. #�y�t,
LOCATION OF SERVICE: �OQ p- ))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 parameters.
C Reduced Pressure Principle
Double Check Valve
Manufacturer C c
Model Number T5 �)5 Y
Serial Number V5 i L1
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
1 /�►�
Located At
The above is certified to be true.
Firm Name -TA hA
Firm Address -� 9 C� C (c 5 i
PWA5 "fix -?5:A -0
Gauge # :�; :� l 7 <i q
Certified Tester
Cart, Tester No.`���'�`l `� � 1 7 Date
Date last accuracy tested "
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
5
DC- Closed
Tight 1
RP -_pSid
Leaked o
Closed Tight
Leaked o
`
Opened at
psid
Opened at
oSid
Did not Open o
osid
Leaked J
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ®
Opened at
Opened at
_osid
Repair
Tight 0
DSid
oSid
RP Sid
The above is certified to be true.
Firm Name -TA hA
Firm Address -� 9 C� C (c 5 i
PWA5 "fix -?5:A -0
Gauge # :�; :� l 7 <i q
Certified Tester
Cart, Tester No.`���'�`l `� � 1 7 Date
Date last accuracy tested "
White - Customer's Copy Yellow - City Copy
Pink - Tester's Copy