2013_1101 (2)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACIGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: ?f^ % A-301"-IA /^i/► 7 D, 24 7:� 7S(
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
❑ Double Check Valve
Manufacturer Gt h ;l• 5
Model Number r- 6) 71-*"/
Serial Number Sy 7��0
TYPE OF ASSEMBLY
C Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
Located At
The above is certified to be true.
Firm Name ' )PS-If r .
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Firm Address 3y5
A)- c <rd,
22L, %
Cert. Tester No. 7-
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight ❑
RP- sid
Leaked C
Leaked ❑
nsid
nsid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight O
Opened at
Opened at
nsid
Repair
Tight ❑
nsid
nsid
RP sid
The above is certified to be true.
Firm Name ' )PS-If r .
c t5 +
lie. Certified Tester y SSPI� I'� Ct i
Firm Address 3y5
A)- c <rd,
22L, %
Cert. Tester No. 7-
Gauge # ors /o11, 6O
Date last accuracy tested 11-1-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy