2014_0213 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Q 9Q QN411 Cn yQJ ` Tx
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.
Reduced Pressure Principle
Double Check Valve
Manufacturer C Q)
Model Number 0 y
Serial Number q Q -1 9
TYPE OF ASSEMBLY
Q Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size t '/.:;) —
Located At U D 4 :�5 �i
The above is certified to. be true.
Firm Name
Firm Address -2 g a C.KS 5-T
ph\1w5 Tx 757
Gauge # '3;2-) l 7 <S q
Date last accuracy tested �Q 3
MR
Certified Tester 6Y1' 0 6 \ W"�
Cart 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
Closed Tight ❑
Opened at
Opened at
nsid
�\
Tight ❑
RP -_ psid
Leaked
nsid
osid
Leaked CV
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Auer
DC- Closed
Closed Tight ❑
Opened at
Opened at
__paid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to. be true.
Firm Name
Firm Address -2 g a C.KS 5-T
ph\1w5 Tx 757
Gauge # '3;2-) l 7 <S q
Date last accuracy tested �Q 3
MR
Certified Tester 6Y1' 0 6 \ W"�
Cart Tester No Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy