2012_0227 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIT'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: e- / -7 /<,'
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
1' Double Check Valve
Manufacturer
Model Number
Serial Nu tuber G'pE''r 6 fl
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size p
Located At
The above is certified to be true.
Firm Name Ae5TjQA1 FIX-9-
Firm Address Fe .3 --q- 72 -7 L"-l'
Gauge #'
Date last accuracy tested
Certified Tester X . -e tX Lft.W '
Cat. Testa No. gpoyr,'6 1S7 Date _t2-
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 -, Lt
2nd Check: Z,
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
p sid
Opened at
osid
--psid
RP- ._psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight a
Opened at
nsid
Opened at
,�nsid
RP sid
The above is certified to be true.
Firm Name Ae5TjQA1 FIX-9-
Firm Address Fe .3 --q- 72 -7 L"-l'
Gauge #'
Date last accuracy tested
Certified Tester X . -e tX Lft.W '
Cat. Testa No. gpoyr,'6 1S7 Date _t2-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy