2012_0612CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: A ,
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
Manufacturer
Model Number
Reduced Pressure Principle
Double Check Valve
lvi4 �� S
Da71,4?'/
Serial Number C� e `/ �
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
G Atmosphere Vacuum Breaker
r/1
Size
Located At
e XK
The above is certified to be true.
Firm Name �� a �- �/' �' Certified Testers
Firm Address ��% !>'v y .7 G��>l TCat. Tester No. 13l'ocff 7 U- Date �-2
Gauge # 0601117!t,0
Date last accuracy tested `'/ -1-2 1-2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Ti& /° -S
Closed Tight 1W
Leaked a a o
Opened at
flsid
Opened at
esid
osid
RP- ,.esid
Leaked 0
Did not Open 0
Leaked 0
Repairs
and
(l
j'i t %�/ < �
aL 7
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_ � sid
Repair
Tight o
nsid
esid
RP sid
The above is certified to be true.
Firm Name �� a �- �/' �' Certified Testers
Firm Address ��% !>'v y .7 G��>l TCat. Tester No. 13l'ocff 7 U- Date �-2
Gauge # 0601117!t,0
Date last accuracy tested `'/ -1-2 1-2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy