2012_0601 (7)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE 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.
c / Reduced Pressure Principle
Double Check Valve
Manufacturer T�so
Model Number bs-0
Serial Number A 9 2 "37.7
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
l�
Size 54, _
Located At I t)AZ" 01W WA-UL
1211 W 4`1
The above is certified to be trot. JAM&
Firm Name Certified Tester S- V;j
Firm Address 21 A (TIN k• W • Cert. Testa No. r (d ` Date
Gauge # MIDIS39
Date last accuracy tested 3, 20 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check
2nd Check
Iteiief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed /ClosedTight
Opened at
Opened at
osid
Tight .-1
RP--.-__psid
Leaked . ❑
osid
osid
Leaked ❑
Did not Open o
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight C3
Opened at
Opened at
P sid
Repair
Tight ❑
esid
osid
RP sid
The above is certified to be trot. JAM&
Firm Name Certified Tester S- V;j
Firm Address 21 A (TIN k• W • Cert. Testa No. r (d ` Date
Gauge # MIDIS39
Date last accuracy tested 3, 20 3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy