2012_1108 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE Y�
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
el—
LOCATION OF SERVICE:
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
Manufacturer
Model Number �S
Serial Number
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At L` Ali
The above is certified to be truce.
Firm Name e/ n �z YL'� Certified Tester
Firm Address -7 41= `'-1 Cert. Tester No. XP6 p °' � LE ;� ate
Gauge # D 7a d'
Date last accuracy tested _? 3�. r �—
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
Ist Check Z
2nd Check /.
Initial Test
DC- Closed
Tight
Closed Tight
Leaked C
Opened at
nSid
Opened at
nSid
nsid
RP -_nsid
Leaked C
Did not Open C
Leaked C
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
DSid
Opened at
�vSid
_nsid
RP sid
The above is certified to be truce.
Firm Name e/ n �z YL'� Certified Tester
Firm Address -7 41= `'-1 Cert. Tester No. XP6 p °' � LE ;� ate
Gauge # D 7a d'
Date last accuracy tested _? 3�. r �—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy