2011_1216CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
r
LOCATION OF SERVICE: �Q 0
t°/l It D ri / u
5(a
The bad -Dow 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 �41) A 1- 6
Model Number 92 0 7 m 3
Serial Number .,Q D d/ d-5
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size Yy
Located At VQ k e- h, F-rt 4 —r,* n Z-0-
The above is certified to be true.
Firm Name /l Certified Tester
Firm Address F4 • W o r4- Z 02V4Cert Tester No. 4/ 5 Date l 2
Gauge # a P1 I00& y'
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
Lo- ,65
DC- Closed
Tight
RP- o�'O Dsid
Leaked ❑
Closed Tight )(
Leaked ❑
a `0
Opened at
Dsid
Opened at
Dsid
Did not Open ❑
Dsid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
Dsid
Opened at
_,Dsid
nsid
RP nsid
The above is certified to be true.
Firm Name /l Certified Tester
Firm Address F4 • W o r4- Z 02V4Cert Tester No. 4/ 5 Date l 2
Gauge # a P1 I00& y'
Date last accuracy tested��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy