2012_0601 (6)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE_V_
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 6 C�) 5 we l/ 4 1
The backilow 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 t&,4 � T S
Model Number 6 & v Af / -
Serial Number --,? V 7 q �,
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
size �' �-
Located At e (I A I, f
The above is certified to be true.
Firm Name /" / / t' Certified Tester ✓�< ° i %�� rJ. � .s
Firm Address i=� �j `' y 7 " ""Ceri. Testa No. !J I�LJ t) C'o ` Dar
Gauge # 0 6 G' Y/ % T.GJ
Date last accuracy tested -/ /,Z -1A
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 /- 4, bC
Closed Tight Y
Leaked /. 'L/ ❑
Opened at
oSid
Opened at
oSid
osid
RP -_psid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
oSid
Opened at
oSid
n sid
RP Sid
The above is certified to be true.
Firm Name /" / / t' Certified Tester ✓�< ° i %�� rJ. � .s
Firm Address i=� �j `' y 7 " ""Ceri. Testa No. !J I�LJ t) C'o ` Dar
Gauge # 0 6 G' Y/ % T.GJ
Date last accuracy tested -/ /,Z -1A
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy