2012_1105CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACRYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
C�►�CS
i
f-' N 1-1
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
Manufacturer
Reduced Pressure Principle
Double Check Valve
�Tw/1 '0,�.
Model Number
Serial Number
X751
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size
Located At L
The above is certified to be true.
Firm Name
Firm AddressI'`
t�
Gauge #
Date last accuracy tested 2>" Ac 12,
Certified Tester J a .,
Cat. Tester No. TT 14 (p I q 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 ❑
psid
nSid
RP-_____psid
Leaked ❑
Did not Open ❑
beaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
psid
Repair
Tight ❑
psid
nSid
RP sid
The above is certified to be true.
Firm Name
Firm AddressI'`
t�
Gauge #
Date last accuracy tested 2>" Ac 12,
Certified Tester J a .,
Cat. Tester No. TT 14 (p I q Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy