2012_1108 (4)CHECK ONE:
IRRIGATION U DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
x�
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
Serial Number J J 9 S Z '7
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
;
Size
Located At Al, (2 mi_ t —
The above is certified to be true.
Firm Name A
Firm Address Ft:;, 9 a j 7 `17
Gauge # e? 1?2
Certified Tester �rltV— d" (-- 9L
Cert. Taster No. 9 P o v l/ 6/ rbiate
Date last accuracy tested 7 --�J - 1 a--
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 1,6
2nd Check: / ,
Initial Test
DC- Closed
/Closed Tight
Opened at
Opened at
vsid
Tight
Leaked o
vsid
vsid
RP -_psid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
. DC- Closed
Closed Tight ❑
Opened at
Opened at
__ nsid
Repair
Tight ❑
vsid
osid
RP sid
The above is certified to be true.
Firm Name A
Firm Address Ft:;, 9 a j 7 `17
Gauge # e? 1?2
Certified Tester �rltV— d" (-- 9L
Cert. Taster No. 9 P o v l/ 6/ rbiate
Date last accuracy tested 7 --�J - 1 a--
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy