2012_1001 (5)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 10 E, La Le
The baclflow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
r-
17
Manufacturer
Model Number
Serial Number
Reduced Pressure Principle
Double Check Valve
i
Yr s it .s
5th
TYPE OF ASSEMBLY
Size
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
7-
Located At 54A CQ
The above is certified to be true.
Firm Name A-{5tki424 F714.(
Firm Address led
6
Gauge #
Date last accuracy tested -7. 12 • 12
'
Certified Tester 'sed3
Cent. Tester No. r,.;, " 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
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
Leaked ❑
osid
nsid
RP - _psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight ❑
Opened at
psid
Opened at
osid
nsid
RP sid
The above is certified to be true.
Firm Name A-{5tki424 F714.(
Firm Address led
6
Gauge #
Date last accuracy tested -7. 12 • 12
'
Certified Tester 'sed3
Cent. Tester No. r,.;, " Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy