2013_0122 (21)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE L.
BACHILOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: — ZOO"
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
C Reduced Pressure Principle ❑ Pressure Vacuum Breaker
2k• Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer �_ i �'�C' .`j Size
Model Number Located At 1 ate Qi�L- 1C S�,
Serial Number 9
The above is certified to be true.
Firm Nana W-24Z4 a e
Firm Address �a j, -� .C- - -75c3 `V o
Gauge # 3 `1 ol 3 3
Date last accuracy tested/ -.) a -13
Certified Tester ,Y %C /L" ,"J
Cent. Tester No.,6 ,1)0 40 7 Date 17 , ,� s-, 0
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 '2
Opened at
Opened at
nSid
_
j
TWA 19
RP•�� sid
Leaked ❑
Leaked ❑
r-
` '
nSid
nSid
Did not Open ❑
Leaked ❑
Reps
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 Nana W-24Z4 a e
Firm Address �a j, -� .C- - -75c3 `V o
Gauge # 3 `1 ol 3 3
Date last accuracy tested/ -.) a -13
Certified Tester ,Y %C /L" ,"J
Cent. Tester No.,6 ,1)0 40 7 Date 17 , ,� s-, 0
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy