2012_1211 (2)ax!�
CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACXnOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
The back -now 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 /3 C-0
Model Number c
Serial Number P-C Q -7l �; 1-
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name
194AIOA
Firm Address 3 V l
Gauge # 7 (,7 6 S74,
Date last accuracy tested 12—(C(-((
Certified Tester
Cert. Testa No. j�(t'(�UO� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight _ ❑
RP -osid
Lca ;ed ❑
Closed Tight ❑
Leaked ❑
Opened at
oSid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
oSid
RP sid
The above is certified to be true.
Firm Name
194AIOA
Firm Address 3 V l
Gauge # 7 (,7 6 S74,
Date last accuracy tested 12—(C(-((
Certified Tester
Cert. Testa No. j�(t'(�UO� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy