2012_0919CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: y/ S — Y2- a-mor D9
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.
❑ Reduced Pressure Principle
Double Check Valve
Manufacturer '1� 4 T�
Model Number 14, () `7m /
Serial Number 5uql�
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
Size ly
Located At F iQF 1, F AL n/ -r, /A' 01 it l
The above is certified to be true. C
Firm Name A--A AlTIO 1�'sA(',�'F/ �' Certified Tester eHRI -57DhiCf< (- 'AFF,0Rn
Firm Address A/W %SAY (X .1 A'E�' Cat Tester No. PAM) �, gl'lb Date
Gauge #
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
Closed Tight Cz
Opened at
Opened at
vsid
Tight C t
Leaked ❑
Leaked ❑
vsid
vsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
vsid
Repair
Tight ❑
vsid
vsid
RP sid
The above is certified to be true. C
Firm Name A--A AlTIO 1�'sA(',�'F/ �' Certified Tester eHRI -57DhiCf< (- 'AFF,0Rn
Firm Address A/W %SAY (X .1 A'E�' Cat Tester No. PAM) �, gl'lb Date
Gauge #
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy