2012_0702CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: //-7
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.
❑
Manufacturer
Model Number
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Size
Serial Number 4 1,5 FS
Located At
The above is terrified to be true.
Firm Name ; 4: J f o 1 12b L k 711/L Certified Tests �_-- ; f , J h r {f t'- / 1
Firm Address ' Z3 S Cert. Tester No. ,2 S 1,,5 Date 7 - .7
'v'It antes; lip %y 7Se37
Gauge # 0,2 D `[ 7
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
7 -:2 - 12-
`=
DC- Closed
Tight c
RP -2sid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
nSid
Did not Open ❑
nSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
nSid
nSid
RP sid
The above is terrified to be true.
Firm Name ; 4: J f o 1 12b L k 711/L Certified Tests �_-- ; f , J h r {f t'- / 1
Firm Address ' Z3 S Cert. Tester No. ,2 S 1,,5 Date 7 - .7
'v'It antes; lip %y 7Se37
Gauge # 0,2 D `[ 7
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy