2012_1108CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
1.111),
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 Principle
Double Check Valve
ManufacturerR.f
Model Number'
Serial Number / S L� `�
TYPE OF ASSEMBLY
❑ Pressure Vacmnn Breaker
❑ Atmosphere Vacuum Breaker
Size e-
Located At AL W,
The above is certified to be true.
Firm Name
Firm Address
Gauge # t) 7 c, ° v 1 - l" )
Date last accuracy tested !1-- 3 i - 12,-
Certified Testery�tiC7i't� Cut Tester No'�, Date
PT' 6 > 645-7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check J :
god Check
Initial Test
DC- Closed
Tight te
osed Tight V
Leaked ❑
Opened at
nsid
Opened at
osid
osid
RP -._— psid
Leaked Cl
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed not ❑
Opened at
osid
Opened at
osid
______p sid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # t) 7 c, ° v 1 - l" )
Date last accuracy tested !1-- 3 i - 12,-
Certified Testery�tiC7i't� Cut Tester No'�, Date
PT' 6 > 645-7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy