2013_0613 (3)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE x
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: e l
4/
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
Manufacturer
Reduced Pressure Principle
Double Check Valve
Model Number 0 0 % ' r
Serial Number y (( e) % -17,
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
size
Located At
The above is certified to be true.
Firm Name &//a "C' /;/ /(- Certified Tester A1(e d1i 11"4*' J
Firm Address f 0 • 13 ° )( % i 7 W " Cert. Taster No. )0 00 Z 6)' Date � -/3 -IJ
Gauge #' 4 G 0 y1,7 9 P
Date last accuracy tested - 5" -/ ir
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 r' 8 Y
Closed Tight ❑
Leaked�,,� ❑
Opened at
DSid
Opened at
nSid
nsid
RP -_psid
Leaked ed ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
_nSid
Repair
Tight ❑
nsid
nSid
RP sid
The above is certified to be true.
Firm Name &//a "C' /;/ /(- Certified Tester A1(e d1i 11"4*' J
Firm Address f 0 • 13 ° )( % i 7 W " Cert. Taster No. )0 00 Z 6)' Date � -/3 -IJ
Gauge #' 4 G 0 y1,7 9 P
Date last accuracy tested - 5" -/ ir
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy