2012_0810CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIO'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
'L0--' Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer %4Ae� Size
Model Number O O % ktA' 4' — Located At
Serial Number 37-72-E&_
The above is cadfied to be true.
Firm Name A
Firm Address F0 'S u '� 19 7
Gauge # 0 ?090498
Date last accuracy tested
Catified ?ester 4-tKA;;6L
Cat Testa No :kP �6 ss' Date ` 1-7—
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
1st Check 2' 0
2nd Check 2.0
Initial Test
DC- Closed
Tight
Closed Tight
Leaked 0
Opened at
psid
Opened at
_,osid
csid
RP- ._.psid
Leaked 0
Did not Open 0
Leaked 0
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight 0
Closed Tight 0
Opened at
flsid
Opened at
____.osid
__ nsid
RP sid
The above is cadfied to be true.
Firm Name A
Firm Address F0 'S u '� 19 7
Gauge # 0 ?090498
Date last accuracy tested
Catified ?ester 4-tKA;;6L
Cat Testa No :kP �6 ss' Date ` 1-7—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy