2013_0411 (19)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: M *0, hoc 0J
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.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
W Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer e C
Model Number
serial Number
Size
Located At
* wq&,; wm
so r 1
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested 7 1 1.)
t 1
Certified Tester
f\ ^,1 ( I,1 i , r.)
Cent. Tester No. YAV 19 41) Date I I 13
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 ❑
nsid
oSid
RP- _pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
osid
Repair
Tight ❑
psid
oSid
RP sid
The above is certified to be true.
Firm Name
Firm Address
Gauge #
Date last accuracy tested 7 1 1.)
t 1
Certified Tester
f\ ^,1 ( I,1 i , r.)
Cent. Tester No. YAV 19 41) Date I I 13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy