2012_1128CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: C .� �- Y A e > t "--
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
^_ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer � Size /
Model Number Located At r 4 -1
Serial Number
The above is certified to be true.
Firm Name
�P+ t Certified Tester n a_., jo A i2
Firm Address 0`"� Cert. Tester No.� Date! 1
Gauge # c
Date last accuracy tested 3t
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- Dsid
Closed Tight 12
Leaked ❑
Opened at
_t�sid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight ❑
Opened at
Dsid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
�P+ t Certified Tester n a_., jo A i2
Firm Address 0`"� Cert. Tester No.� Date! 1
Gauge # c
Date last accuracy tested 3t
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy