2012_0629 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE;
2,&-Z
--- , I & au'va"'Ja
V--
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
t' Double Check Valve
Manufacturer
Model Number
Serial Number - `rt'
TYPE OF ASSEMBLY
• Pressure Vacuum, Breaker
• Atmosphere Vacuum Breaker
Size 3/q
Located At 1 4 C
`Ge U-Vk4w
The above is certified to be true.
Firm Namci''�S�D
Firm Address
Y, —i Z
Gauge # 090W ��O
Date last accuracy tested 3— 20 ^i
I I � 5
Certified Tester ��
Cent Tester NoV 100 9 Date b-
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
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight el
Tight
Leaked ❑
Xlosed Tight
Leaked 2.0 C3
Opened at
Dsid
Opened at
nsid
Did not Open o
nsid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nsid
_ nsid
RP sid
The above is certified to be true.
Firm Namci''�S�D
Firm Address
Y, —i Z
Gauge # 090W ��O
Date last accuracy tested 3— 20 ^i
I I � 5
Certified Tester ��
Cent Tester NoV 100 9 Date b-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy