2012_0316CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: E(- 7 M P1 A
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 Reduced Pressure Principle
❑ Double Check Valve
Manufacturer gC'z)
Model Number es-0 _`
Serial Number "�%.�- -?,,P/ 9'
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At 7-1- it
The above is certified to be true.
/ kj A t2 !Z , l 14 ( xl
Firm Name t� � � R � Cemfied Tcst�er
Firm Address 3 qO ( ��-4�j Cert. Tester No. " Z31 ,5Z Date _ z
Gauge # , l ---> 6 >1
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 Cheri:
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
osid
Opened at
osid
osid
RP -_psid
Leaked ❑
3
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nsid
Opened at
osid
osid
RP sid
The above is certified to be true.
/ kj A t2 !Z , l 14 ( xl
Firm Name t� � � R � Cemfied Tcst�er
Firm Address 3 qO ( ��-4�j Cert. Tester No. " Z31 ,5Z Date _ z
Gauge # , l ---> 6 >1
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy