2014_0213 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE' V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # N 2F rpf\(N47, -)
LOCATION OF SERVICE: � 4Q 5�)A TX -� 5 0 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.
LC / Reduced Pressure Principle
9' Double Check Valve
Manufacturer V f 6 n
�yModel Number Q
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to,be true.
Firm Name -Tc\
Firm Addr+ess-7 � " 5-'
'POAS Tk 75:1.,7
Gauge # 3'- 10 i5 q
Date last accuracy tested �
Certified Tester �C %cam ` t)} C U MV,
Cent Tester No Date 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
DC- Closed
Closed Tight ❑
Opened at
Opened at
trsid
\Tight
❑
RP -_psid
Leaked
osid
_ osid
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Afar
DC- Closed
Closed Tight ❑
Opened at
Opened at
_osid
Repair
Tight ❑
Dsid
osid
RP sid
The above is certified to,be true.
Firm Name -Tc\
Firm Addr+ess-7 � " 5-'
'POAS Tk 75:1.,7
Gauge # 3'- 10 i5 q
Date last accuracy tested �
Certified Tester �C %cam ` t)} C U MV,
Cent Tester No Date I
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy