2012_1012CHECK ONE: ,
IRRIGATION DOMESTIC V FIRELINE
BACICFLOW PREVENTION ASSEMBLY TEST AND MAEVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
c Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
�,,�
MManufacturer � size
Model Number Qa 7 i—t i'? Located At /V.,e
Serial Number .96013
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Gauge # O 1 u j o 4 ,'8
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
ist Check f a ,P
2nd Checkt
Initial Test
DC- Closed
Tight er
Closed Tight
Leaked O
Opened at
�psid
Opened at
_�nsid
d
RP -- _„paid
Lea ked O
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed o
Tight
RP sid
Closed Tight O
Opened at D
Opened at Q
Sid
m.
The above is citified to be true.
Firm Name Certified Testa
Firm Addross a B L, 7 j -z Cart. Testa No. XP,-- ( VIS-1 Date,_:
Gauge # O 1 u j o 4 ,'8
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy