2012_0601 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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
Reduced Pressure Pn=ple
Double Check Valve
Manufacturer
Double Check Valve Assembly
Model Number
7�1
Serial Numbed
V-/? f y
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name �j G/ �Q /� -- Certified Tester ///,/,
Firm Address " �' l%G X % �l x cat Tester No. Date
Gauge # 71�
Date last accuracy tested y l /_;?--
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 �l `7� `9�
Closed Tight '2`
Leaked ,,? 6// 0
Opened at
nsid
Opened at
nsid
nsid
RP -_ psid
Leaked C
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
—_---p sid
Repair
Tight o
nsid
�psid
RP sid
The above is certified to be true.
Firm Name �j G/ �Q /� -- Certified Tester ///,/,
Firm Address " �' l%G X % �l x cat Tester No. Date
Gauge # 71�
Date last accuracy tested y l /_;?--