2012_0601 (2)CHECK ONE:
IRRIGATION DOMESTIC t/
FIRELINE
BACT4LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: C� bZ 3 3 t C • +1 N e �� C Pn �� 7
The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC
rezulanons and is certified to be operating within acceptable parameters.
T-YYE Or AS SEMBLY°
Reduced Pressure Principle C Pressure Vacuum Breaker
Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer Size
Model Number '52S "t- L Located At I Al S.4+h '4) A,1(
Scrial Number
The above is certified to be true.
Firm Name gkk . lac' -S +i G__ Certified Testa ilia'( C ,4 , .m N
Firm Address 1? 8aSe' Cent Testa No.nP Q,� t 010 1i Date
'3>6- N-1-c>,4, 7x -7 1W2
Gauge # 1) "2L 3 fj c
Date last accuracy tested -t j -a-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
Ist Check:
2nd Check:
Initial Test
DC- Closed
Closed Tight El'
ed�at�
(
Opened at
oSid
,-
Ti Z
Leaked
- �sl_..PSid
oSid
id
i
Leaked C
Did not Open D
Leaked
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
osid
Repair
Tight C
DSid
osid
RP sid
The above is certified to be true.
Firm Name gkk . lac' -S +i G__ Certified Testa ilia'( C ,4 , .m N
Firm Address 1? 8aSe' Cent Testa No.nP Q,� t 010 1i Date
'3>6- N-1-c>,4, 7x -7 1W2
Gauge # 1) "2L 3 fj c
Date last accuracy tested -t j -a-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy