2012_0629CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: Rm ujQ_ s-a._ �S'u. ei L 1. Q-
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer re- h en Size '
Model Number 255(0 Located At
Serial Number &)n
The above is certified to be true.
Firm Name -L-Vn i L re. rd ' c (.L r
Firm Address , 1
"7 t- f r p
Gauge # O:Sj X395 )_
Date last accuracy tested L JS - I L
Certified Testa �L(,) i S (r r) k-rC I
Cat Testa No. 1 Ol &..q 3 Date -1 ?—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1 st Check
2nd Check 19
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight )K
Closed Tight X
Leaked o
Opened at
nsid
Opened at
vsid
psid
RP -_ psid
Leaked C
Did not Open o
Leaked C
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
n sid
Repair
Tight a
nsid
nsid
RP sid
Ji
The above is certified to be true.
Firm Name -L-Vn i L re. rd ' c (.L r
Firm Address , 1
"7 t- f r p
Gauge # O:Sj X395 )_
Date last accuracy tested L JS - I L
Certified Testa �L(,) i S (r r) k-rC I
Cat Testa No. 1 Ol &..q 3 Date -1 ?—
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy