2011_0611T H E G 1 T V O F
COPPELL
CHECK ONE:
X ^ 5 l 8
IRRIGATION DOMESTIC V FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D.
7
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduce Pressure Principle ❑ Pressure Vacun= Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number Located At 17 �'S �'y' y e� "1 �e e y
Serial Number 2 Z/ 3 }�
The above is certified to be true.
Firm Name 1 -A Fire & Domestic Testing_
Firm Address P.O.Box 79548 Ft Worth Tx 76179
Gauge # 0073178 or 06070576
Date last accuracy tested Dec 02 2010
Certified Tester Brian L. Wagoner %CELL # 817- 247 -4799
Cent Tester No. BP0006562 Date C
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tim
RP- //l nsid
Closed Tight
Leaked ❑
71 Z—
Opened #t
2 ' G' nsid
Opened at
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test ARer
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 1 -A Fire & Domestic Testing_
Firm Address P.O.Box 79548 Ft Worth Tx 76179
Gauge # 0073178 or 06070576
Date last accuracy tested Dec 02 2010
Certified Tester Brian L. Wagoner %CELL # 817- 247 -4799
Cent Tester No. BP0006562 Date C
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy