2011_1025CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE /
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 bees tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle a Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Cis 4 Size 9
Model Number 1)196--,2 Located At
Serial Number q6( o6- U T.45 s e .x
The above is certified to be true.
Firm Name AC ) 4' /- C ' "Certified Tester �`'i %e ✓> / �4 u
Firm Address PC' i3 c x -7 t' 7 xi , or
Tester No. �� ��"' `' ° � � Date or fG , � - i/
Gauge # v 6' 0 "-1 / 7 � c,
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
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Checi:
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
-�
Tight ❑
Leaked ❑
RP- 2. �psid
Leaked ❑
_psid
_osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
_psid
osid
RP sid
The above is certified to be true.
Firm Name AC ) 4' /- C ' "Certified Tester �`'i %e ✓> / �4 u
Firm Address PC' i3 c x -7 t' 7 xi , or
Tester No. �� ��"' `' ° � � Date or fG , � - i/
Gauge # v 6' 0 "-1 / 7 � c,
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy