2012_0629 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: (,I C,,� 5r
The back-Dow 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
x )
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ,C Size ,
Model Number` Located At
Serial Number C0 5 C 2,,J= JJ-
The above is certified to be true.
Firm Name !J(rA I F1 Ce QAA L-01 U r i
Firm Address( 9 Nrn2, &i.,i i1
Fer h- %,sTX`76. 1 Jc,,
Gauge #
Date last accuracy tested (D- ,;),5 - J 2-
Certified Tester Tr .6 u S CC r -%A re.11
Cert. Tester No. (WW, I y (o y -3 Date Cc 1 -) 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 ,.),L
2nd Cheri: j , '
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
vsid
Opened at
nsid
nsid
RP- _,.psid
Leai;e ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed not ❑
Opened at
nsid
Opened at
osid
� sid
RP sid
The above is certified to be true.
Firm Name !J(rA I F1 Ce QAA L-01 U r i
Firm Address( 9 Nrn2, &i.,i i1
Fer h- %,sTX`76. 1 Jc,,
Gauge #
Date last accuracy tested (D- ,;),5 - J 2-
Certified Tester Tr .6 u S CC r -%A re.11
Cert. Tester No. (WW, I y (o y -3 Date Cc 1 -) Z.
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy