2012_0716 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND AIAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `b51 k--) • tk'44 - %-,A D� 1.5Y,a5
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
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Rrv�vS Size W
Model Number 3000 SS Located At
Serial Number 1y-12 \"l
The above is certified to be true.
Firm Name ,L � Certified Tester
Firm Address 45'1 �1� �� Cat Testa No. Moo 141 %�e Date 1 3 ti 3
Gauge # Oloo'1nt 4
Date last accuracy tested -1 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
DC- Closed
Tight
RP- 1—psid
Leaked o
Closed Tight
Leaked o
Opened at
Dsid
Opened at
nsid
Did not Open o
nsid
Leaked a
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight o
Closed Tight a
Opened at
csid
Opened at
osid
_ osid
RP psid
The above is certified to be true.
Firm Name ,L � Certified Tester
Firm Address 45'1 �1� �� Cat Testa No. Moo 141 %�e Date 1 3 ti 3
Gauge # Oloo'1nt 4
Date last accuracy tested -1 1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy