2012_1012CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: 2 L c " - (: " -�
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.
TYPE OF ASSEMBLY
C / Reduced Pressure Principle ❑ Pressure Vacuum Breaker
3' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number 3 y4�4
Size
Located At C i'(1dt
The above is certified to be true.
Firm Name L'$' I P
-))h*hW4 gl )G � Firm Address
Gauge #
Date last accuracy tested 1
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Tight ❑
Leaked ❑
oSid
nSid
RP- __psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nSid
RP sid
The above is certified to be true.
Firm Name L'$' I P
-))h*hW4 gl )G � Firm Address
Gauge #
Date last accuracy tested 1
Certified Tester
Cert. Tester No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy