2012_0208 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclMow 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 a Pressure Vacuum Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer j�lr9 TTS Size 3N
Model Number DO 7 M l Located At se- C orc of prep •- U•.� 1�-
Serial Number Sly
The above is certified to be true.
Firm Name /'// %e..5 Certified Testes P Z^ 2 ° ti �n 11
Fum Addresses o (�� yx 1. ayY Cert. Tester No. l3 ? �3 � Date
Gauge # OW/ 0 v 69
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
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
RP -sid
Closed Tight
Leaked ❑
Opened at
vsid
Opened at
nsid
nsid
Leaked o
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC-Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
_psid
_____—p sid
RP sid
The above is certified to be true.
Firm Name /'// %e..5 Certified Testes P Z^ 2 ° ti �n 11
Fum Addresses o (�� yx 1. ayY Cert. Tester No. l3 ? �3 � Date
Gauge # OW/ 0 v 69
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy