2011_0725 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
LO
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
❑ Double Check Valve
Manufacturer `s 4-f --?
Model Number C C)
Serial Number
�qy 16
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
^ rr
Size Z
Located At I1A v I/,7
The above is certified to be true.
Firm Names v '�
Firm Address
fr✓ ti � k I..�vt- x
Gauge #
Date last accuracy tested
Certified Tester
G. V" t i (,�- : ( f. 4 Y.n S
Cert. Tester No. 0411 `i j 19 Date -7 - Z I'' ) I
�--1y, i
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 ❑
Opened at
Opened at
osid
Tight ❑
si
Leaked ❑
osid
osid
Lea ;ed
Did not Open ❑
Leaked C3
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_ osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be true.
Firm Names v '�
Firm Address
fr✓ ti � k I..�vt- x
Gauge #
Date last accuracy tested
Certified Tester
G. V" t i (,�- : ( f. 4 Y.n S
Cert. Tester No. 0411 `i j 19 Date -7 - Z I'' ) I
�--1y, i
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy