2013_0522CHECK ONE:
IRRIGATION
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DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: Y Y1 I ►`-�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.
Manufacturer
Model Number
Serial Number
TYPE OF ASSEMBLY
Reduced Pressure Principle ❑ Pressure Vacuum Breaker
Double Check Valve G Atmosphere Vacuum Breaker
wn4 -) Size I„I 2
�.✓ I Located At
rn-,� W&
b `.t6 Cow mac -ht rvQ,
The above is certified to be true.
Firm Name 1%C�. I (fir Certified Tester
Firm Address no 5 CP(�(J�� i t 1 [� Cat. Tester No. P)F1 2 � �' Date 13
Gauge # I 0c, V0 1 O��U
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 Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight 1-d
Opened at
Opened at
oSid
Tight ❑
Leaked ❑
psid
oSid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
oSid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name 1%C�. I (fir Certified Tester
Firm Address no 5 CP(�(J�� i t 1 [� Cat. Tester No. P)F1 2 � �' Date 13
Gauge # I 0c, V0 1 O��U
Date last accuracy tested
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy