2012_0208 (3)CIIECK ONE:
IRRIGATION
DOMESTIC FIRELINE A--�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: o2 O % S
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.
Reduced Pressure Principle
Double Check Valve
Manufacturer WA -7-7-S
Model Number 7 % yx 1) CD ✓+
Serial Number / 0 O S7 `/
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At L/e, / /Vd Lo r AAr 0-1 D10P
The above is certified to be true. /
Firm Name o/% /e`s 4- Certified Tester ✓ �`° K ti �..�
Firm Address x� ,.✓o c -Vl. 7'n 7& 4Y Cert. Tester No. Q OO13 Date -2- Sr- /a
Gauge # 0(.&110-0&9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight
Opened at
Opened at
osid
JS
Ti
RP� psid
Leaked o
oSid
oSid
Leaked ❑
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
_ nsid
Repair
Tight E3
oSid
oSid
RP sid
The above is certified to be true. /
Firm Name o/% /e`s 4- Certified Tester ✓ �`° K ti �..�
Firm Address x� ,.✓o c -Vl. 7'n 7& 4Y Cert. Tester No. Q OO13 Date -2- Sr- /a
Gauge # 0(.&110-0&9
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy