2011_1128CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE�_
BAOCMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
ass :xefAUK�-
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
Manufacturer
Model Number
TYPE OF ASSEMBLY
Reduced Pressure Principle a Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
�
r j
it S 4 Size ,
/r"/� Located At 5 l�-- ,
Serial Number
The above is certified to be true.
�
�;{ C
Firm Name pig- c Certified Testa
Firm Address ��� Bc� 7 `t 7 U� /�i? Cent. Testa No. � C'" IC Date
Gauge # z ' 0 � � t // /' � �)
Date last accuracy tested
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
nsid
Tight ❑
Leaked ❑
nsid
nsid
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
e�'�'•
Materials
�j �� h- f%'
`'
Used
Test After
DC- Closed /�
Closed Tight 9K
Opened at
Opened at
_______nsid
Repair
Tight 4t"
/�
psid
osid
RP !
The above is certified to be true.
�
�;{ C
Firm Name pig- c Certified Testa
Firm Address ��� Bc� 7 `t 7 U� /�i? Cent. Testa No. � C'" IC Date
Gauge # z ' 0 � � t // /' � �)
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy