2011_0725 (3)CHECK ONE:
IRRIGATION
DOMESTIC_ _
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL:
LOCATION OF SERVICE: ti c
The baci low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is cerdfied to be operating within acceptable parameters.
C
71
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
U-1 i i t% , S
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name e P ✓ `'
Firm Address 0 `�) o y w 2
Gauge # Ij � I ( I
Date last accuracy tested
Certified Tester
Cert. Tester No. &Ay i ' ,3 -/ Date i' 2 = 41
-0- 11
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 -2
RP -_psid
Leaked ❑
Closed Tight
Leaked ❑
Z , 2
Opened at
osid
Opened at
nsid
Did not Open C3
nsid
Leaked C3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
vsid
Opened at
nsid
nsid
Rp sid
if
The above is certified to be true.
Firm Name e P ✓ `'
Firm Address 0 `�) o y w 2
Gauge # Ij � I ( I
Date last accuracy tested
Certified Tester
Cert. Tester No. &Ay i ' ,3 -/ Date i' 2 = 41
-0- 11
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy