2011_1025 (3)09
CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 615"5-
1 5 5 1�:- L f e fd ' �-
The bacldlow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
❑ Reduced Pressure Principle
DDouble Check Valve /l
Manufacturer fl-5 e
Model Number
Serial Number 015'13 3&
TYPE OF ASSEMBLY
❑ Pressure Vacuimr Breaker
❑ Atmosphere Vacuum Breaker
size
Located At SyU � 1.�au I r
The above is certified to be true.
Firm Name
c, o i L Certified Tester
Firm Address / / 7� 7 1 LN >r-' Cert. Tester No. 'c c a
� z Date
Gauge # C" G 1 "/ / 7 `� L;
Date last accuracy tested � 12
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
n
C f
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check:
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
oSid
oSid
R.P-j,.�psid
% L/
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_osid
Repair
Tight ❑
oSid
oSid
RP sid
The above is certified to be true.
Firm Name
c, o i L Certified Tester
Firm Address / / 7� 7 1 LN >r-' Cert. Tester No. 'c c a
� z Date
Gauge # C" G 1 "/ / 7 `� L;
Date last accuracy tested � 12
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy