2012_0227CHECK ONE: !
IRRIGATION y DOMESTIC FIRELINE
BAC{FLOW PREVENTION ASSEMBLY TEST AND MAUVITNANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. # /
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and mah tained as rcqwred by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
/ Reduced Pressure Principle C Pressure Vacuum Breaker
ie t Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer X L1411 0 Size 2- p �
Model Number yo Located At Al, S-•- j!2
Serial Number /Sg 2 -1-'"
The above is certified to be true.
Firm Name /1 MI Dn! Fl �a
Firm Address PiG ?q'7 t�
Gauge # U 7 e �c7 q &8
Date last accuracy tested F- I - ► I
Ce ifiad Tester
Cent. Tester No. S Pvy G i, 7 Date 7--L - L-
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
Ist Check j,
2nd Check,
Initial Test
DC- Closed
Tight e
Closed Tight e
Leaked ❑
Opened at
_ Dsid
Opened at
osid
_ osid
RP- ._psid
L,Ca;ed ❑
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight o
Opened at
nsid
Opened at
sid
____-nsid
RP sid
The above is certified to be true.
Firm Name /1 MI Dn! Fl �a
Firm Address PiG ?q'7 t�
Gauge # U 7 e �c7 q &8
Date last accuracy tested F- I - ► I
Ce ifiad Tester
Cent. Tester No. S Pvy G i, 7 Date 7--L - L-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy