2013_1212 (4)CHECK ONE:
IRRIGATION DOMESTIC FIRELINE A
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE: 3U .
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 W r I � "/A C.
Model Number 3 5 O 5 A
Serial Number 3 5 r7,;2 �
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size
Located At �o�f
The above is certified to be true.
Firm Name , l i r G n _ , C �� Certified Tester
Firm Address �'� 3 E t : o r wao� clr Cat Tester No.
Gauge # � 2 7- q(0
Date last accuracy tested
Date
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
Tight ❑
Closed Tight ❑
Leaked ❑
Opened at
psid
Opened at
oSid
osid
RP -_pSid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nSid
Repair
Tight ❑
Sid
oSid
RP sid
The above is certified to be true.
Firm Name , l i r G n _ , C �� Certified Tester
Firm Address �'� 3 E t : o r wao� clr Cat Tester No.
Gauge # � 2 7- q(0
Date last accuracy tested
Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy