2011_1025 (4)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE / `
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
g Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number U `I 12 L 1
Size
Located At
The above is certified to be true.
Firm Name /yc
Firm Address � "-' /3 c x 71 7
Gauge # G% G / / 7 � Z'
Date last accuracy tested
15'-.2-//
Certified Tester 1`'41 %ft- L&:
Cert. Tester No. l 3 /�'E "` ' ' ° ' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
�,295 f
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check:
Initial Test
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Tight ❑
Leaked o
osid
osid
Ri-osid
Leaked ❑
1
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test Allen
DC- Closed
Closed Tight o
Opened at
Opened at
_____.p sid
Repair
Tight Cl
psid
osid
Rp sid
The above is certified to be true.
Firm Name /yc
Firm Address � "-' /3 c x 71 7
Gauge # G% G / / 7 � Z'
Date last accuracy tested
15'-.2-//
Certified Tester 1`'41 %ft- L&:
Cert. Tester No. l 3 /�'E "` ' ' ° ' Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy