2013_0411 (21)CHECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE:
Cep 1� T>�
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.
Manufacturer
Reduced Pressure Principle
Double Check Valve
4
Model Number `� ` f� i
Serial Number
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name C
Firm Address
Gauge # ' r n
Date last accuracy tested -711 i.s /) J
Certified Tester
Cert. Tester No. `?,, Q 01 y L " 7 Date l
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
nsid
RP -_psid
Leaked ❑
Did not Open ❑
Leaked ❑
Repairs
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 C
Firm Address
Gauge # ' r n
Date last accuracy tested -711 i.s /) J
Certified Tester
Cert. Tester No. `?,, Q 01 y L " 7 Date l
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy