2013_0122 (34)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW 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
Z
Double Check Valve
Manufacturer
R Al\� e' n5
Model Number
vccic,
Serial Number 115 19- C)
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At 1 CI 4_
The above is certified to be true.
Firm N ` it
. 0r n C/- ?•e%.
Firm Address C- aWand Tx 75—Oq D
Gauge # 3,1 Z3 5-3
Date Last accuracy tested % , 2 . /,3
Certified Testa Z //i f'0 o13 /? tit) (7
Cat. Testa No4&01 D 77.3 Date , :25 - I3
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 �r
Opened at
Opened at
osid
Tight M
Leaked ❑
psid
osid
' S
RP- I ` Lpsid
Leaked ❑
'
Did not Open C3
Leaked E3
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight o
Opened at
Opened at
-------- psid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm N ` it
. 0r n C/- ?•e%.
Firm Address C- aWand Tx 75—Oq D
Gauge # 3,1 Z3 5-3
Date Last accuracy tested % , 2 . /,3
Certified Testa Z //i f'0 o13 /? tit) (7
Cat. Testa No4&01 D 77.3 Date , :25 - I3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy