2014_0213 (8)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE, v
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: �Od 9C UU+h m Act h Co Poc l 1 Tx -� 5 d 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.
C Reduced Pressure Principle
Q1 Double Check Valve
Manufacturer s-i � C 0
Model Number CPS
Serial Number N&
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to.be true.
Firm Name
Firm Address Cy C.c c 5i"
1PW,),5 TPc 7 5 7
Gauge # ��23 t 7 S 9
Date last accuracy tested -�d A
Certified Tester
Cent. Tester No.�'� �i �� 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
Tight o
RP -_psid
Closed Tight ❑
Leaked
ebpened at
vsid
Opened at
_osid
vsid
Leaked
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
–___—.p sid
Repair
Tight ❑
–� sid
osid
RP sid
The above is certified to.be true.
Firm Name
Firm Address Cy C.c c 5i"
1PW,),5 TPc 7 5 7
Gauge # ��23 t 7 S 9
Date last accuracy tested -�d A
Certified Tester
Cent. Tester No.�'� �i �� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy