2013_0122 (10)CHECK 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 detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
C Reduced Pressure Principle
A Double Check Valve
Manufacturer
Model Number
Serial Number 131 2-H
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At X. L Lk t /" cri C Gja f�
The above is certified to be true.
Firm Name u J tf-Lt
')ao,; n GK
Firm Address
Gauge # :3 7 2- 3 S- 3
Date last accuracy tested 1 - - 9 ° /3
Certified Testa , d Z= d tya'171cl zllm
Cat. Testa No. ,�JW16 77.3 Date 11 ` d 5-- /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
7
DC- Closed
Tight
RP- r Sid
Leaked ❑
Closed Tight 15�
Leaked ❑
Opened at
osid
Opened at
oSid
Did not Open o
osid
Leaked ❑
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight Cl
CIosed Tight ❑
Opened at
nSid
Opened at
psid
sid
RP sid
The above is certified to be true.
Firm Name u J tf-Lt
')ao,; n GK
Firm Address
Gauge # :3 7 2- 3 S- 3
Date last accuracy tested 1 - - 9 ° /3
Certified Testa , d Z= d tya'171cl zllm
Cat. Testa No. ,�JW16 77.3 Date 11 ` d 5-- /3
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy