2012_1012 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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 C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer -11-12 L Size
Model Number S
Serial Number mr,
Located At
24,
The above is certified to be true.
Firm Name
Firm Address%i (0� "r wcc _ 6, �� � �r ✓1_'f1
Gauge # 19 1(
Date last accuracy tested _� - ZQ- /,�
s /I
Certified Tester_
Cert. Testa No. I I%�r. r Date t2 lZ
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
osid
Tight ❑
Leaked ❑
osid
nsid
RP- _psid
Lzaked ❑
Did not Open o
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
osid
RP sid
The above is certified to be true.
Firm Name
Firm Address%i (0� "r wcc _ 6, �� � �r ✓1_'f1
Gauge # 19 1(
Date last accuracy tested _� - ZQ- /,�
s /I
Certified Tester_
Cert. Testa No. I I%�r. r Date t2 lZ
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy