2013_0411 (12)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: / Ua'
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
❑ Reduced Pressure Principle C Pressure Vacuum Breaker
❑ Double Check Valve C Atmosphere Vacuum Breaker
Manufacturer
C., Size
Model Number 5 i Located At jt�,a R
Serial Number 6/1 1.5
The above is certified to be taste.
Firm Name -FO�141 F/
Firm Address
TX -7, w
Gauge #
Date last accuracy tested 7/1 (1
Certified Tester r '` - I r
Cert Testa No. V n 1 H q 17 Date ' -1/1� ��
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
,1ec,
Tight 13
RP- psid
Leaked Cl
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
nsid
osid
RP sid
The above is certified to be taste.
Firm Name -FO�141 F/
Firm Address
TX -7, w
Gauge #
Date last accuracy tested 7/1 (1
Certified Tester r '` - I r
Cert Testa No. V n 1 H q 17 Date ' -1/1� ��
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy