2013_1001CIIECK ONE:
IRRIGATION__ DOMESTIC
FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
0
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 ; i
Model Number
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size
Located At
The above is certified to be /tnu. q03 --
Firm Name
Firm Address' �'7 ' t :� 1�, �W
Gauge # ?-- � ? 71
Date last accuracy tested ? (✓
Certified Testa
Cat. Testa No. �`-l� —Date E
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 ❑
Leaked ❑
DSid
oSid
R.P -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test Ater
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be /tnu. q03 --
Firm Name
Firm Address' �'7 ' t :� 1�, �W
Gauge # ?-- � ? 71
Date last accuracy tested ? (✓
Certified Testa
Cat. Testa No. �`-l� —Date E
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy