2012_1001 (4)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAC MOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `t-,N Le— �e K'
The backflow 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 !-44
Model Number .7 llCD4 - C V
Serial Number '322
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
o Atmosphere Vacuum Breaker
Size
Located At CJ hd ge r ,Le
TUM BREAKER
Check Valve
osid
Leaked ❑
The above is certified to be true.
Firm Name 'idle( Certified Tester
Firm Address ' ` ' Cert. Tester No. '' ' T' `' "` Date ,
Gauge # JgL-n
Date last accuracy tested %- 12 -12
osid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VAC1
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
RP -.1,"6 psid
Leaked ❑
Did not Open ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
RP sid
TUM BREAKER
Check Valve
osid
Leaked ❑
The above is certified to be true.
Firm Name 'idle( Certified Tester
Firm Address ' ` ' Cert. Tester No. '' ' T' `' "` Date ,
Gauge # JgL-n
Date last accuracy tested %- 12 -12
osid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy