2012_1012 (2)CHECK ONE:
IRRIGATION tr DOMESTIC FIRELINE
BACKFLOW PREVENnON ASSEMBLY TEST AND MAVUENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ///'g
The bacidlow 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 a Pressure Vacuum Breaker
( Double Check Valve o Atmosphere Vag Breaker
Manufacturer Size
Model Number �-�0'D Located At
Serial Number
Gauge #
Date bast accuracy tested
WNW - 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 /,!0
2nd Check 7-;L-
Initial Test
DC- Closed
Tight te.,
,Closed Tight 14e
Leaked ❑
Opened at
__psid
Opened at
-----.psid
_Psid
RP- ,_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight
Closed Tight ❑
Opened at
sid
Opened at
sid
___--psid
RP
The above is certified to be true.
Firm Name A LL- , ri ,-e Certified Tester
Firm Address f 013& V� -7 ti > Cert. Testa No. i3P o-'v & rS'7 Date/ v
Gauge #
Date bast accuracy tested
WNW - Customer's Copy Yellow - City Copy Pink - Tester's Copy