2011_1128 (2)CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACHTLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: `1-
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
} Double Check Valve
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
Size __-
Located At
The above is certified to be true.
Firm Name /J (` // 1' /" l" /.e t
Firm Address P4 l3" x' 7? / 't /% XN,
Gauge # 61; y V l 7 Y t%
Date last accuracy tested
Certified Tester
xx, Ae
Cert. Testa No. lilac c�e -) 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 &'
Opened at
Opened at
osid
Tight /- (" V
Leaked - C
osid
_osid
RP -_psid
Leaked o
Did not Open O
Leaked o
Reps
and
n,
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
--- nsid
Repair
Tight C3
nsid
osid
RP sid
The above is certified to be true.
Firm Name /J (` // 1' /" l" /.e t
Firm Address P4 l3" x' 7? / 't /% XN,
Gauge # 61; y V l 7 Y t%
Date last accuracy tested
Certified Tester
xx, Ae
Cert. Testa No. lilac c�e -) Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy