2012_0601 (3)BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: l'
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.
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size �y
Located At S /C/" / G� y✓�� ��
e A x
Reduced Pressure Principle
Double Check Valve
Manufacturer
a�/ -/ S
Model Number
'71 f4l
Serial Number
�; 7 y�
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size �y
Located At S /C/" / G� y✓�� ��
e A x
The above is certified to be true. /
Firm Name 4!: l/ 10 /�� Certified Tester /� P
Firm Address _ /�1.�%� �r� �� �Cert. Testa No. lylmeG 76a Date �-
Gauge # 65'60 VI/ le'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
Ist Check
2nd Check:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed /-
Closed Ti t
Opened at
Opened at
osid
Tight
Leaked o
osid
osid
RP- _psid
Leaked o
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
sid
Repair
Tight o
osid
osid
RP sid
The above is certified to be true. /
Firm Name 4!: l/ 10 /�� Certified Tester /� P
Firm Address _ /�1.�%� �r� �� �Cert. Testa No. lylmeG 76a Date �-
Gauge # 65'60 VI/ le'
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy