2014_0213 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 9(�U-t� r"(%C -� 0 1
The bacidlow 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
s( Double Check Valve
Manufacturer rte" cc)
Model Number Q 5 1
Serial Number -3 `i 15
TYPE OF ASSEMBLY
M Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size I /�
Located At V31D * :a q
r
The above is certified to be true.
Firm Name 7c�
Firm Address 7 g a q C -oS r 5-T
P MA5 Tk 75ttal
Gauge # 3 30<6q
Certified Tester
Cent Testa No 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
Ist Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Ti W2t e
RP -_psid
Leaked
osid
osid
Leaked
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
-.p sid
Repair
Tight o
�psid
�psid
RP sid
r
The above is certified to be true.
Firm Name 7c�
Firm Address 7 g a q C -oS r 5-T
P MA5 Tk 75ttal
Gauge # 3 30<6q
Certified Tester
Cent Testa No Date
Date last accuracy tested _
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy