2013_0122 (39)CIIECK ONE:
IRRIGATION
DOMESTIC
FIRELINE X,
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
LOCATION OF SER
CITY OF COPPELL
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
Double Check Valve
Manufacturer
Model Number C;
Serial Number I (0 i `-1
TYPE OF ASSEMBLY
• Pressure Vacuum Breaker
• Atmosphere Vacuum Breaker
size )
Located At e T4,NJ T -Zy-.J 6, e�,
The above is certified to be true.
Firm Name 4 U' U Certified Tester Wl
;�n.os ..71 cW,�
Firm Address roc!'... ix 75'0 'A0 Cent. Tester No Date � ` � 5-' /3
Gauge # 3 r?,9 3 S 3
Date last accuracy tested / -d -2 ` /3
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 Ut'
Opened at
Opened at
nsid
t Cc._5`J
Ti ter
���� Dsid
Leaked ❑
Leaked ❑
,
nsid
nsid
Did not Open ❑
Leaked ❑
Repairs
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
vsid
RP sid
The above is certified to be true.
Firm Name 4 U' U Certified Tester Wl
;�n.os ..71 cW,�
Firm Address roc!'... ix 75'0 'A0 Cent. Tester No Date � ` � 5-' /3
Gauge # 3 r?,9 3 S 3
Date last accuracy tested / -d -2 ` /3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy