2012_1211CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Z . z c.) D
The baclflow 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 ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �G-{] Size
Model Number = Located At
Serial Number 44(.- V-71 / "'�
The above is certified to be true.
A--9 t P-P
Firm Name n
11�- / ,-
Firm Address C --mow
Gauge #�
Date last accuracy tested t 7--
Certified Testa�Y�'
Cat. Testa No. RQbj r> Z Date = Z—
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- . o 6 Dsid
Closed Tight ❑
Leaked ❑
Opened at
Dsid
Opened at
nsid
nsid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight Cl
Closed Tight ❑
Opened at
Dsid
Opened at
Dsid
nsid
RP sid
The above is certified to be true.
A--9 t P-P
Firm Name n
11�- / ,-
Firm Address C --mow
Gauge #�
Date last accuracy tested t 7--
Certified Testa�Y�'
Cat. Testa No. RQbj r> Z Date = Z—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy