2012_1001 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 5. ` j� t
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
J.
Manufacturer (•L .44 4
Model Number ,7S-7 Or DKl - 6
Serial Number _r6 -
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size ?3
Located At Cu r rip ( el A CWf r �L+a
The above is certified to be true.
Firm Name ? hVers4 %ed
Firm Address
Gauge #
Date last accuracy tested 7 ! 1 ! 2
Certified Testa JOSfek
Cat. Testa No. 9PQ0!- jo'i Date 10=
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 ❑
RP- -4d�psid
Leaked ❑
Closed Tight ❑
Leaked ❑
Opened at
nSid
Opened at
oSid
Did not Open ❑
oSid
Leaked ❑
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
nSid
Opened at
oSid
nSid
RP sid
The above is certified to be true.
Firm Name ? hVers4 %ed
Firm Address
Gauge #
Date last accuracy tested 7 ! 1 ! 2
Certified Testa JOSfek
Cat. Testa No. 9PQ0!- jo'i Date 10=
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy