2012_0227 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE 611�'
BACKnOW 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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
3-- Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer A &ee -.� Size
Model Number Tb c'---
Serial Number 001/17
Located At 5-e-,
The above is certified to be true.
Firm Name Arm o A,� ri -m--
Firm Address PO-F,19 % 1 -7-_I-le-l-
Gauge # 0 7 o cl'u 4-,$)?
Date last accuracy tested dY- I - r I
Certified Tester .tee
Cent. Testa No_ Pe '', & r,S 7 Date -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check /,
2nd Check (, 67
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
_psid
Opened at
+nsid
nsid
RP -_psid
Leaked C
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
sid
_�� sid
RP sid
The above is certified to be true.
Firm Name Arm o A,� ri -m--
Firm Address PO-F,19 % 1 -7-_I-le-l-
Gauge # 0 7 o cl'u 4-,$)?
Date last accuracy tested dY- I - r I
Certified Tester .tee
Cent. Testa No_ Pe '', & r,S 7 Date -
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy