2012_0511CHECK ONE:
IRRIGATION
FIRELINE Y
BACKFLOW PREVENTION ASSEMBLY TEST AND AIAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. # [ Qua
LOCATION OF SERVICE: 601 � 0 J L_ AJ
The backnow prevention assembly detailed below has been tested and maintained as required by TNRCC
rtgulatiaos and is certified to be operating within acceptable parame=.
TYPE OF ASSEMBLY
C Reduced Pressure Principle a Pressure Vacm= Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer rr Spy , size
31�
Model Number Located At 5W Cv 2 nGE jZ
serial Number 991363
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Doable Check Valve Assembly
1st Check
tad Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight )ZI`
Opened at
Opened at
� d
Ti
Tight
Leaked O
_ Dsid
� osid
R
Leaked p
Did not Open O
Leaked O
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_____psid
Repair
Tight o
osid
�psid
ymmmogtg
The above is certified to be mm.
Firm Name Ar f o v-► L1¢C= 5 Certified Tester i 1 V IL-mrJ
Firm Adds n Po L&Dq -K 7 Cat. Testa No. 6P1,Q1Q &5) Date Sin
_f tc
Gauge # 06/007S
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy