2011_1025 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: y S � t� " ,/"C" t
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.
Reduced Pressure Principle
* Double Check Valve
Manufacturer
Model Number C '2
Scrial Number G
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At J
5 r IC-14-I= < c s y c'.,q K s Ica .t
YT/ o Trt e,
The above is certified to be true.
Firm Name /� c" �� �� r / / �` Certified Tester Z' c
Firm Address U . c Y 7 Y 7�� ��' T Cert. Tester No. P40 �� a Date
Gauge # C G �, ./ j 7 < <Z'
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 Check
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
vSid
nsid
R.P -2,2:_psid
Leaked C3
Did not Open ❑
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name /� c" �� �� r / / �` Certified Tester Z' c
Firm Address U . c Y 7 Y 7�� ��' T Cert. Tester No. P40 �� a Date
Gauge # C G �, ./ j 7 < <Z'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy