2011_1025 (2)CHECK ONE:
IRRIGATION_
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 5 >' Cfc c- P ®/ f 1�/fli
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 Y
Serial Number 1122-64,
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name /)c � 1 L- � � �r�
Firm Address D. i3 e ;7? 7
Gauge # 6,& o r I 7'-e' o
Date last accuracy tested '
Certified Tester c l /// r4 u s
Cem Tests No. ����`' �'`' ��''� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Tight C3
Leaked 13
Sid
_pSid
RP- /' A Dsid
Leaked ❑
' O
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_____—p sid
Repair
Tight ❑
psid
_pSid
RP sid
The above is certified to be true.
Firm Name /)c � 1 L- � � �r�
Firm Address D. i3 e ;7? 7
Gauge # 6,& o r I 7'-e' o
Date last accuracy tested '
Certified Tester c l /// r4 u s
Cem Tests No. ����`' �'`' ��''� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy