2012_0217 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE - X
BACSFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: I
The backtlow 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 ❑ Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
i A ii
4s,
Size
Model Number
-7-74
Located At
VOL O 1,
OptW& 0,C r V6
Serial Number ID ` ,qO I
The above is certified to be true.
Firm Name k_�011fifill- 4106S
Firm Address 02 b ._% 7
Gauge # a W216
Date last accuracy tested 5 I 1 1
Cert. Tester No. 06 S Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
S
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight
Closed Tight /<
Leaked ❑
Opened at
asid
Opened at
osid
osid
RP- ._._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_ nsid
RP sid
The above is certified to be true.
Firm Name k_�011fifill- 4106S
Firm Address 02 b ._% 7
Gauge # a W216
Date last accuracy tested 5 I 1 1
Cert. Tester No. 06 S Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy