2012_1012CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
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.
C
n
Manufacturer
Reduced Pressure Principle
Double Check Valve
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size 41q
Model Number / Located At
Serial Number ( ��
The above is certified to be true.
. o 611 ��}
Firm Name �' � %4 � �' n Certified Tester
Firm Address e"(2 `•� 04 Cert. Tester No. S Z Date
Gauge #
Date last accuracy tested
(312v-`
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.— ❑
Closed Tight ❑
Leaked ❑
Opened at
nsid
Opened at
nSid
vsid
RP -1 sid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
nSid
nSid
RP sid
The above is certified to be true.
. o 611 ��}
Firm Name �' � %4 � �' n Certified Tester
Firm Address e"(2 `•� 04 Cert. Tester No. S Z Date
Gauge #
Date last accuracy tested
(312v-`
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy