2013_1024CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACxFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ` - Y \ V
The bacUow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable par=eters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve G Atmosphere Vacuum Breaker
Manufacturer
Model Number
Serial Number ' J rA 1
Size
Located At a" V—V kA
The above is certified to be true.
Firm Name °4'1E �ir'hrl t 11
Firm Address
Gauge # ()L (` <;3 ()]
Date last accuracy tested
Certified Tester 1 G �,1�� � C Co k�
Cert. Tester No. _ Date C)
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
nsid
Tight ❑
Leaked ❑
nsid
osid
RP- ___nsid
J�T(�
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
osid
nsid
RP sid
The above is certified to be true.
Firm Name °4'1E �ir'hrl t 11
Firm Address
Gauge # ()L (` <;3 ()]
Date last accuracy tested
Certified Tester 1 G �,1�� � C Co k�
Cert. Tester No. _ Date C)
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy