2011_1216 (2)CHECK ONE:
IRRIGATION
DOMESTIC Z
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
k--e -I-
5 (�
LOCATION OF SERVICE: Pj ) /V. -�� n ton e P
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 Fob C O
Model Number $ 5n
Serial Number 47,j O$cP
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
p,e ►►
Size
Located At nd -e r
►'t_.
The above is certified to be true.
nn �
Firm Name
�"� Certified Testa ZOq'21-
Firm Address �� �l/ o r f 7 (o w Cc rt Tester No. 00/3S Date = 11
Gauge # 0(Q 11d0Cp9
Date last accuracy tested �f-
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
4�5
DC- Closed
Tight nn X
RP- sid
Leaked p
Closed Tight
Leaked �j o
Opened at
nsid
Opened at
osid
Did not Open o
osid
Leaked a
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight Cl
Closed Tight o
Opened at
sid
Opened at
vsid
______p sid
RP sid
The above is certified to be true.
nn �
Firm Name
�"� Certified Testa ZOq'21-
Firm Address �� �l/ o r f 7 (o w Cc rt Tester No. 00/3S Date = 11
Gauge # 0(Q 11d0Cp9
Date last accuracy tested �f-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy