2013_0906 (16)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BACK LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baclflow 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
Model Number
Serial Number %?
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name 4)P I r0 C em sH
Firm Address u /.217%T ✓��.��,'h
Th -266)
Gauge # -
Date last accuracy tested
Certified Tester
!s�%?r ;'r'f ('
Cert. Tester No. . Date
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 ❑
Opened at
Opened at
osid
Tight ❑
RP -psid
Leaked ❑
Leaked ❑
osid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 4)P I r0 C em sH
Firm Address u /.217%T ✓��.��,'h
Th -266)
Gauge # -
Date last accuracy tested
Certified Tester
!s�%?r ;'r'f ('
Cert. Tester No. . Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy