2011_1128 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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
�C Double Check Valve
Manufacturer ��r 5
Model Number (�'
Serial Number 1 `/ / ;'2 /
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size �y
Located At A/ 1�'
The above is certified to be true.
Firm Name
Firm Addr s 1�9
Gauge # -7
Date last accuracy tested
Cat Tester No. �� � ��'� -,7��' 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
Tight /;,
Closed Tight A
Leaked /= O ❑
Opened at
nsid
Opened at
_osid
osid
RP -_L_psid
Leaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_--.p sid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Addr s 1�9
Gauge # -7
Date last accuracy tested
Cat Tester No. �� � ��'� -,7��' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy