2012_0919CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bad&ow 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
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve Oc- TtcTCP, o Atmosphere Vacuum Breaker
Manufacturer l L, 114 TTY Size /1 " % //
Model Number %�) ` ?IYAA Located At n F /?F AlA . //° t,Iiq ML F
Serial Number ,Z / S 5 Ll Ll
The above is certified to be true.
Firm Name SAL l (/E- RAIrLO -a'
Firm Address 1 i0/h FMAy 1W.
Gauge # L&,,? �?
Date last accuracy tested 42-1,'11-11
j - � --
Certified Tester llkw "p-'Ha (-, Fnap
Cert. Tester No. 6AMI 91 /- Date
FEAM
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
�A
DC- Closed
Tight JS(
RP -V, D Sid
!
Closed Tight A
Leaked ❑
f
Opened at
nsid
Opened at
�oSid
nsid
'
Leal ed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nSid
Opened at
nsid
RP sid
The above is certified to be true.
Firm Name SAL l (/E- RAIrLO -a'
Firm Address 1 i0/h FMAy 1W.
Gauge # L&,,? �?
Date last accuracy tested 42-1,'11-11
j - � --
Certified Tester llkw "p-'Ha (-, Fnap
Cert. Tester No. 6AMI 91 /- Date
FEAM
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy