2012_0508CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: /O Z-"'
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
erJ Double Check Valve
Manufacturer
Model Number &5-0
Serial Number I+ C. _ 7-5M 3
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size > /(/
Located At
L,
The above is certifier) to be true.
Firm Name 6 r1'"DA aP
0
Firm Address ?' qO I
Gauge # r0/A4 12,6 CC) 3 q 6
Certified Tester
Cert. Tester No. 3 �SZ Date = 2
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 ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
osid
psid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
osid
RP sid
The above is certifier) to be true.
Firm Name 6 r1'"DA aP
0
Firm Address ?' qO I
Gauge # r0/A4 12,6 CC) 3 q 6
Certified Tester
Cert. Tester No. 3 �SZ Date = 2
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy