2012_0227 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND A ABVITXANCE 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 dN4'
Model Number X07 On
Serial Number 4pe) (.3
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name AZ!?� �-
Firm Address fc' &Y 7 f7 �✓
Gauge #
Date last accuracy tested F. f - tt
Certified Tester
Cart. Tester No. $ P P-°- & /S Date = -7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1st Check f . 8
2nd Check -2, `�
Initial Test
DC- Closed
Tight W
Closed Tight
Leaked C
Opened at
sid
Opened at
sid
nsid
RP- ._.psid
Leaked C
Did not Open C
Leased
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight C
Closed Tight o
Opened at
__psid
Opened at
__paid
_ asid
RP sid
The above is certified to be true.
Firm Name AZ!?� �-
Firm Address fc' &Y 7 f7 �✓
Gauge #
Date last accuracy tested F. f - tt
Certified Tester
Cart. Tester No. $ P P-°- & /S Date = -7
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy