2012_0716 (3)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: `M �J • ► "`"�Ar�1�,,C VNA - %an� o�i 1-ty -S
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.
Reduced Pressure Principle
Double Check Valve
Manufacturer
Model Number 00-1 tLl
Scrial Number Ro; 0O iy
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size vho
Located At 0 C"A't�-
The above is certified to be true.
Firm Name
AA ),t6� Certified Tester
Firm Address y54% M4! kG �? �'"^^' ^ Cent Tester No. Date 1 3 u
Gauge # 01r 0-11'1 q j
Date last accuracy tested
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- a_0 �psid
Leaked ❑
Closed Tight
Leaked ❑
Opened at
asid
Opened at
asid
Did not Open ❑
asid
Leaked O
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
asid
Opened at
osid
sid
RP sid
The above is certified to be true.
Firm Name
AA ),t6� Certified Tester
Firm Address y54% M4! kG �? �'"^^' ^ Cent Tester No. Date 1 3 u
Gauge # 01r 0-11'1 q j
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy