2012_0208 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE t�—'
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 020
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.
C Reduced Pressure Principle
Double Check Valve
Manufacturer in! A —1 S
Model Number O o -7 A& t
Serial Number S-41-5051
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 3�5�
Located At V, -v /- l/V C &0 1 rv—� v 1� ? T e P
The above is certified to be true.
Firm Name a >/ 7;e s +- Tester Pe- Y ^ �" 9 YA
ySyfr Mach +n �.�� viGO Lei
Firm Address -�� + �c% r V k x '1 q Cert. Tester No.`R�'o 10) Iq l Date a
Gauge # 06p 11 O1)60 e
Date last accuracy tested g -S" //
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight en W,
RP -sid
Closed Tight
Leaked ❑
Opened at
sid
Opened at
osid
vsid
Leaked o
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
�nsid
sid
RP sid
The above is certified to be true.
Firm Name a >/ 7;e s +- Tester Pe- Y ^ �" 9 YA
ySyfr Mach +n �.�� viGO Lei
Firm Address -�� + �c% r V k x '1 q Cert. Tester No.`R�'o 10) Iq l Date a
Gauge # 06p 11 O1)60 e
Date last accuracy tested g -S" //
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy