2011_1128 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE_�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: V S5 % / r c AG ,� P
The back-flow prevention assembly detailed below has been tested and maintained as reqwed by TNRCC
regulations and is certified to be operating within acceptable parameters.
C
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
� C
Y C/ / r 7 e)
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At 5; LL Ul �,
The above is certified to be true.
Firm Name AC) It, « T 11( --e
Firm Address P & ,i / 7 �' 7 t U xd,
Gauge # 0&&L-11 7 ,1' 6'
Date last accuracy tested
Certified Tester A 116 Gli, /lf If "" 5
Cart. Tester No. M- '&00 ; "' Date % /-.;2 -� —//
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 l' L�
Tight s
Closed Ti- t -Q(
Leaked / y ❑
Opened at
nsid
Opened at
_nsid
nsid
RP -_ psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
osid
vsid
RP sid
The above is certified to be true.
Firm Name AC) It, « T 11( --e
Firm Address P & ,i / 7 �' 7 t U xd,
Gauge # 0&&L-11 7 ,1' 6'
Date last accuracy tested
Certified Tester A 116 Gli, /lf If "" 5
Cart. Tester No. M- '&00 ; "' Date % /-.;2 -� —//
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy