2013_0122 (15)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly derailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle ❑ Pressure Vacuum Breaker
a Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size Z
Model Number Located At
Serial Number `t
The above is certified to be true.
Gauge # 3 ? 2 3 53
Date last accuracy tested % - Q2, 13
. - --
Cart. Tester No'�[�l0 7 7 -� 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 V
Opened at
Opened at
nsid
f-eL,S
Tight X
Leaked ❑
Leaked ❑
p
nsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
sid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Gauge # 3 ? 2 3 53
Date last accuracy tested % - Q2, 13
. - --
Cart. Tester No'�[�l0 7 7 -� Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy