2012_1012 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /// b The bacidlow prevention assembly detailed below has been tested and maintained as required by TNRCC
reguladws and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Size �J >,
Manufacalrer J
Model Number e lc- Located At
Serial Number 92 94 � 3 y
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER
Double Check Valve Assembly
ist Check Z, V 2nd Check 7,-A Relief Valve Air Inlet Check Valve
Initial Test DC- Closed losed Tight Opened at Opened at _—ps id
Tight 4210 Leaked ❑ _psid ----psid
RP- ___—,psid
Leaked ❑ Did not Open ❑ Leaked
Lan
DC-Closed Closed Tight o Opwed at Opened at
light ❑ paid aid
RP d
The above is certified to be true.
Firm Name Catified TCSW
Firm Address P,9 13 P Y- 2 5 -2 t�lAll- Cart. Tester No.B P _ Date
Gauge # 07 v 1 v 4 Y?
Date last accuracy tested '7- 3 ( - f —
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy