2014_0213 (6)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE ' d/
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # c y1 N V5 t M o—A—)
LOCATION OF SERVICE: 13 )A N\+xc �O-h u ( Ct),20,M -yx -� a 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.
Reduced Pressure Principle
2 Double Check Valve
Manufacturer �,e b C n
Model Number X05 y
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size I t —.
Located At Vj7) � p 4o2-3
r .
The above is certified to.. be true.
Firm Name
r
Firm Address a C -t?� i `S"T
'Dhk\�N5 Tk 75 �
Gauge # � 0<69
Date last accuracy tested
Certified Testers
Cent. Tester No.';�Ml qI 0 Date 3 !
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 o
cued at
Opened at
nsid
Tight ❑
Leaked tv
_psid
nsid
�
RP -_psid
Leaked
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight ❑
_nsid
esid
RP sid
r .
The above is certified to.. be true.
Firm Name
r
Firm Address a C -t?� i `S"T
'Dhk\�N5 Tk 75 �
Gauge # � 0<69
Date last accuracy tested
Certified Testers
Cent. Tester No.';�Ml qI 0 Date 3 !
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy