2011_1128 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ' S /5/ e C /C" A �
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
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
Cd/,fi { f 5
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At f'� Al e
The above is certified to be true.
Firm Name
Firm Address
Gauge # 0 0 c -/ 1 I ,, G'
Date last accuracy tested � ";? - l /
Certified Tester
/11, ht^ Z,�-,; //, �4 IV
Cent. Tester No. l3 ' `'c,) ' Gf Date / /-� e —
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
Tight I- �
Closed Tight �&
Leaked ❑
Opened at
DSid
Opened at
oSid
osid
RP- ._psid
Leaked ❑
Did not Open o
Leaked o
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_______p sid
Repair
Tight ❑
Sid
osid
RP Sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # 0 0 c -/ 1 I ,, G'
Date last accuracy tested � ";? - l /
Certified Tester
/11, ht^ Z,�-,; //, �4 IV
Cent. Tester No. l3 ' `'c,) ' Gf Date / /-� e —
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy