2013_0426CHECK ONE:
IRRIGATION
DOMESTIC
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FIRELINE
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BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 1-i 0c)
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
,V Double Check Valve 0 Atmosphere Vacuum Breaker
Manufacturer V) ri T Size 3 t
Model Number 00 '� � � Located At ,Ae t) I&C t3
Serial Number
The above is certified to be true. Y { 5
Firm Name .4 j r t
Firm Address ( ) ,K 75, 7
Gauge #
Date last accuracy tested 3113
Certified Tester L&kqw--
�,�
Cert. Tester No. aid 1 l 3 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 kV
Opened at
Opened at
esid
Tight ,e C1
RP -psid
_
Leaked .+O' I 13 a
osi d
nsid
Leaked
Did not Open o
Leaked o
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
_nsid
Repair
Tight o
nsid
nsid
RP sid
The above is certified to be true. Y { 5
Firm Name .4 j r t
Firm Address ( ) ,K 75, 7
Gauge #
Date last accuracy tested 3113
Certified Tester L&kqw--
�,�
Cert. Tester No. aid 1 l 3 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy