2012_0629 (2)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE C
BACIGLOW PREVENTION ASSEMBLY TEST AND MAWMNANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle M Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer 6 V�C r'y Size N
Model Number RL5 _Y Located At 5 per C- L
Serial Number tJ l ) zct A)1 e
The above is certified to be true.
Firm Name ( e �. Le CAM , ib r urn Y
Firm Address �(
Gauge # ()'� 1 t - S 1
Date last accuracy tested (Q j
Certified Tester —F t j
Cert. Testa No. R?CJ) )1 q to q 3 Date -- 3q - 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 I .
2nd Check 1. �
Initial Test
DC- Closed
Closed Tight X
Opened at
Opened at
nsid
Tight 'K
Leaked ❑
nsid
nsid
s
R.P -,_ Dsid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ( e �. Le CAM , ib r urn Y
Firm Address �(
Gauge # ()'� 1 t - S 1
Date last accuracy tested (Q j
Certified Tester —F t j
Cert. Testa No. R?CJ) )1 q to q 3 Date -- 3q - I Z
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy