2012_0601CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPEL L
LOCATION OF SERVICE:
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.
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
,�&x //"5-
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
/r
Size
6- C) *�,w � Located At
q �) V Fl- _-1
The above is certified to be true.
Firm Name - Certified ified Tester
Firm Address ��� 7 �� ` Cat Tester No. jf'�riaD Date
Gauge # �i Ali X17 4L�
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
Tight
Closed Tight X
Leaked - d o
Opened at
Sid
Opened at
sid
nsid
RP- pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
,_,___p sid
Repair
Tight
Sid
nSid
RP sid
The above is certified to be true.
Firm Name - Certified ified Tester
Firm Address ��� 7 �� ` Cat Tester No. jf'�riaD Date
Gauge # �i Ali X17 4L�
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy