2012_1001 (3)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1410 1 la ,,44 LAS ,
The back low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is ccrtified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer It )&4 4 5 Size 31,1" "
Model Number f)07N1 32 Located At
Serial Number r,%� de-k
The above is certified to be true.
Firm Name
Firm Address
Gauge # °'N i7T / s
Date last accuracy tested -7 1'2 - P!,
Certified Testa e+
Cent. Tests No. $Pop 1 ?' ' n ` Date
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 ❑
Closed Tight ❑
Leaked ❑
Opened at
vsid
Opened at
osid
osid
RP-_L sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
flsid
Opened at
osid
vsid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge # °'N i7T / s
Date last accuracy tested -7 1'2 - P!,
Certified Testa e+
Cent. Tests No. $Pop 1 ?' ' n ` Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy