2012_0928 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINEE�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bw*flow prevention assembly detailed below has been tasted and maintained as required by TNRCC
regulations and is certified to be operating within acceptable pis.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacuum Breaker
X— Double Check Valve C Atmosphere Vacuum Breaker
Manufacuaer �� Size
Model Number Located At �C
Serial Number qq 1 q z 6
The above is certified to be true.
Firm Name d�a. _ r` 1114- Certified Tester
Firm Address P o 30v- 7177 Cent Tester No. F P c 1SG p
Gauge # 0 2 P9,9 q .? Y
Date last accuracy tested i - 1 '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 2.2
2nd Check Z , v
'ef Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
-Closed Tight
Leaked o
Opened at
4sid
Opened at
_,_,,,_paid
___.psid
RP- ._paid
Leaked p
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
RP 'd
Closed Tight o
Opened at
sid
Operi d at
osid
__psid
The above is certified to be true.
Firm Name d�a. _ r` 1114- Certified Tester
Firm Address P o 30v- 7177 Cent Tester No. F P c 1SG p
Gauge # 0 2 P9,9 q .? Y
Date last accuracy tested i - 1 '2_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy