2012_1108 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIULOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The backnow 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
Manufacturer F& L (:,A,
Model Number 9S
Serial Number 0 4/ 0/7 O I
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name c--- 's -"'-_ �Y� Sr Certified Tester fi n •ter Fe.� C�-
Firm Address P v ?,- v V- 7 y L%rx� cat Testa No. F F ,,,-, 0-5' /mate
Gauge # e)'7 v iro 41JIF
Date last accuracy tested '-7- 3 i � ) -,Z-_
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 . w
2nd Check , 0
Initial Test
DC- Closed
Tight 9K
Closed Tight
Leaked ❑
Opened at
tfsid
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
�vsid
____-p sid
RP sid
The above is certified to be true.
Firm Name c--- 's -"'-_ �Y� Sr Certified Tester fi n •ter Fe.� C�-
Firm Address P v ?,- v V- 7 y L%rx� cat Testa No. F F ,,,-, 0-5' /mate
Gauge # e)'7 v iro 41JIF
Date last accuracy tested '-7- 3 i � ) -,Z-_
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy