2012_0716CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `651 IJ • K4 ��� 0�
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/ Reduced Pressure Principle
Double Check Valve
Manufacturer �vS
Model Number 20461
Serial Number VPC
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size 3� ,
Located At :s V w, .
The above is fcertified to be true.
Firm Name
Firm Address `15` MAJl -n AX
Gauge # Olio- 11"1$4
Date last accuracy tested -1 lu rz
Certified Tester
Celt Testa No. V0014-1'bu Date 1
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
�a55
DC- Closed
Tight ') i
RP- I_
Leaked C
Closed Tight
Leaked C3
Opened at
osid
Opened at
osid
Did not Open C3
paid
Leaked C3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
osid
Opened at
osid
_� sid
RP Sid
The above is fcertified to be true.
Firm Name
Firm Address `15` MAJl -n AX
Gauge # Olio- 11"1$4
Date last accuracy tested -1 lu rz
Certified Tester
Celt Testa No. V0014-1'bu Date 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy