2012_0810 (3)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE v
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bac.lflow 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
1_ Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve O Atmosphere Vacuum Breaker
Manufacturer A1- sire
Model Number ED C- Located At
Serial Number 2n 41
The above is certified to be true.
Firm Name Fi-,z-, �)�S
Firm Address PO g -1 Y-- ?'" L"L" 17L
Gauge # e2"71-90j-,?9
Date last accuracy tested -7 3 ! - ► 2
Certified Testes Xn e /-� CanA&e-*�—
Cent. Tester No. 9F van 61-5- % Date ? -1 n - / z"
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 /.
tad Check
Initial Test
DC- Closed
Tight
Closed Tight
Leaked o
Opened at
nsid
Opened at
�flsid
,.paid
RP -_psid
Leaked C
Did not Open o
Leaked D
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight o
Opened at
asid
Opened at
�vsid
_nsid
RP sid
The above is certified to be true.
Firm Name Fi-,z-, �)�S
Firm Address PO g -1 Y-- ?'" L"L" 17L
Gauge # e2"71-90j-,?9
Date last accuracy tested -7 3 ! - ► 2
Certified Testes Xn e /-� CanA&e-*�—
Cent. Tester No. 9F van 61-5- % Date ? -1 n - / z"
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy