2012_0104CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: C _7 �? �
The back low 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 -< d : Size
Model Number
5 U Located At /.� " i�✓� � � --� -� p -�
Serial Number %4 Q / / .T c,- -I—
The above is certified to be true.
Firm Name 'f ,��� •,f /_� > : �� Certified Tester —,114" ,-,�_f S u
Firm Address u f' . - s '11 pert Tester No.� P00(.47 4 Z Date
Gauge #,'I c (� ��/ "�� =' " , s.✓ 0 4
Date last accuracy tested 1 - '/ / L
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 .
RP- _-_.psid
Leaked ❑
Closed Tight
Leaked C3
,
Opened at
__psid
Opened at
nsid
Did not Open ❑
nsid
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
vSid
___—p sid
RP sid
The above is certified to be true.
Firm Name 'f ,��� •,f /_� > : �� Certified Tester —,114" ,-,�_f S u
Firm Address u f' . - s '11 pert Tester No.� P00(.47 4 Z Date
Gauge #,'I c (� ��/ "�� =' " , s.✓ 0 4
Date last accuracy tested 1 - '/ / L
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy