2014_0213 (7)CHECK ONE: /
IRRIGATION DOMESTIC FIRELINE' v
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: �4Q 13(A Co w'M -'x -� 5 p i q
The backtow prevention assembly detailed below has been tested and maiatained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuum Breaker
T� Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer C C-13 Size /�-
Model Number S05- Located At
Serial Numberr— Ll Q
The above is certified to be true.
Firm Name 7A cN\ `;T\ �' k
Firm Address 7 q 5-T
"`x 75,Aal
Gauge # 3 30<6q
Date last accuracy tested �Q
Certified Tester
CerG Tester No.�'C�tl�}V`7 Date 3 l
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
erred at
Opened at
osid
Tight G
RP -_psid
Leaked
osid
_ osid
Leaked
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
___p sid
Repair
Tight ❑
osid
esid
RP sid
The above is certified to be true.
Firm Name 7A cN\ `;T\ �' k
Firm Address 7 q 5-T
"`x 75,Aal
Gauge # 3 30<6q
Date last accuracy tested �Q
Certified Tester
CerG Tester No.�'C�tl�}V`7 Date 3 l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy