2013_0411 (26)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACMOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
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.
❑ Reduced Pressure Principle
O Double Check Valve
Manufacturer C r
Model Number
Serial Number (� o o 1 g a
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size i /Z)-
Located At
�'\ S, (- K r`,V\
The above is certified to be true.
Firm Name T t ` f
Firm Address
Gauge # -a ? n
Date last accuracy tested Vi U % 16-1
Certified Tester I � (
Cert. Tester No. S�Y)o I' Date
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
c= ,
Tight ❑
R.P -_psid
Leaked ❑
nSid
nSid
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 true.
Firm Name T t ` f
Firm Address
Gauge # -a ? n
Date last accuracy tested Vi U % 16-1
Certified Tester I � (
Cert. Tester No. S�Y)o I' Date
White — Customer's Copy Yellow — City Copy Pink — Tester's Copy