2014_0213 (9)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: 5C A Nm\c �yyk v ( Go vie t l T-A -� 5 0 I q
The bacltilow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e l Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number
Serial Number P63 X56 LQ
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
size 1, /j
Located At loy -# a o
The above is certified to,be true.
Firm Name —�c�'�
Firm AddrM. 7 9c� i C K c 5"f
PWo%5 TX ?5D,--)�
Gauge # 3 31 ? <� q
Date last accuracy tested
'. ,;, � � � �-; Z��z
Certified Tester ail '
Cert. TesterNo 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 O
/Opened at
Opened at
nsid
\
Tight ❑
RP -_psid
Leaked IQ(
Leaked
psid
nsid
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ psid
Repair
Tight D
psid
nsid
RP sid
The above is certified to,be true.
Firm Name —�c�'�
Firm AddrM. 7 9c� i C K c 5"f
PWo%5 TX ?5D,--)�
Gauge # 3 31 ? <� q
Date last accuracy tested
'. ,;, � � � �-; Z��z
Certified Tester ail '
Cert. TesterNo Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy