2012_1001CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: l'+ 1 ] - d,
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.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuum Breaker
C Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer WAfl S Size -31 %4
Model Number 001 N13 Located At S E • col n e r 2�1
Serial Number
The above is certified to be true.
Firm Name hw E
Firm Address z,9 41 M Id!+
Gauge # D40,' � I-1
Date last accuracy tested 7- 11 - It.
Certified Tester 4% fiawn
Cat. Tester No. &00* 10`1 Date 1"7-!, 1
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy
PRESSURE VACUUM BREAKER
REDUCED PRESSURE PRINCIPLE ASSEMBLY
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tight ❑
RP -_ 1 psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
oSid
Did not Open o
psid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
psid
psid
RP sid
The above is certified to be true.
Firm Name hw E
Firm Address z,9 41 M Id!+
Gauge # D40,' � I-1
Date last accuracy tested 7- 11 - It.
Certified Tester 4% fiawn
Cat. Tester No. &00* 10`1 Date 1"7-!, 1
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy