2012_0928CHECK ONE:
IRRIGATION- DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 6 2— ( 5-• P o
The backflow 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 -Fi- ,$C-e-
Model Number �F5r
Serial Number A 67'7 f
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
sin
Located At /q - W -
The above is certified to be true.
Firm Name
Firm Address
Gauge # P 7J- yFr4L F F
Date last accuracy tested 7" 31- f z-,
Certified Tester /-/
Cent Tester No. E ��'Z'v /-g' Date 2—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check f, (o
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight ❑
Leaked
Opened at
tasid
Opened at
_psid
osid
RP- __,psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
l `�
Materials
Used
Test After
Repair
DC- Closed
Tight
RP sid
Closed Tight e
2,
Opened at
p sid
Opened at
osid
d
The above is certified to be true.
Firm Name
Firm Address
Gauge # P 7J- yFr4L F F
Date last accuracy tested 7" 31- f z-,
Certified Tester /-/
Cent Tester No. E ��'Z'v /-g' Date 2—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy