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CHECK ONE:
IRRIGATION
DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: JCY -Se-L4 (11 i kr- s S 1) b S I `-L 3 S • J)?4 4nn Tai .p,P k. , Se-. 12-c C�p�el l` 1, D19
The baclflow 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 L �
Model Number i)C2
Serial Number L� �1 I y cl
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
O Atmosphere Vacuum Breaker
II
size /Z
Located At
The above is certified to be true.
Firm Name l $ 'Ft VT-� D�)rn e�,71c� A�
Firm Address PD - t%X 19 S14P3 � ;Tx
"1(P x-19
Gauge # \&jatj-T«Ctj E O 0-1311 e)
Date last accuracy tested \- : 3, I�L
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
RP --),6— psid
Leaked o
Leaked o
I. -k
3•N pSid
oSid
Did not Open D
Leaked J
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight o
osid
oSid
RP sid
The above is certified to be true.
Firm Name l $ 'Ft VT-� D�)rn e�,71c� A�
Firm Address PD - t%X 19 S14P3 � ;Tx
"1(P x-19
Gauge # \&jatj-T«Ctj E O 0-1311 e)
Date last accuracy tested \- : 3, I�L
White - Customer's Copy
Yellow - City Copy
Pink - Tester's Copy