2012_1005CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Va(eui s °? 'A-f, vet CyraSP
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ' n S Size
Model Number o ,ti T Located At
Serial Number 357'1775 L.2/- (; r 1 51211 10114 6 / 3 '1 `
The above is certified to be true.
Firm Name '2—
Firm Address " 1,2 / leiJa42 r
�e Id, T'k 7600
Gauge # ) 20 7a
Date last accuracy tested
Certified Tester 0 76
Ccrt. Tester No.Pr ^' n ",•/ Date �d
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 --2
Leaked ❑
Closed Tight ❑
Leaked o
Opened at
usid
Opened at
usid
Did not Open o
usid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
flsid
Opened at
usid
usid
RP sid
The above is certified to be true.
Firm Name '2—
Firm Address " 1,2 / leiJa42 r
�e Id, T'k 7600
Gauge # ) 20 7a
Date last accuracy tested
Certified Tester 0 76
Ccrt. Tester No.Pr ^' n ",•/ Date �d
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy